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Background An appendicostomy (ACE) is a surgical option for antegrade enemas in children with severe constipation and/or fecal incontinence who have failed medical management. In 2019, we initiated an expedited post-operative protocol and sought to examine our short-term outcomes compared with our historical cohort. Methods A retrospective review was performed of all children undergoing ACE between 2017 and 2020. Children were excluded if they underwent an associated procedure (e.g. colon resection). Patients were divided into two cohorts: historical cohort (2017–2018, Group A) and the expedited protocol (2019 to present, Group B). The primary outcome was length of stay. Results 30 patients met inclusion (Group A = 16, Group B = 14). The most common indications for ACE were constipation (50%) and constipation or fecal incontinence associated with anorectal malformation (43%). Group B experienced a decreased length of stay (1 vs 3 days, P = 0.001) without differences in 30-day surgical site infection (7.1% vs 18.8%, p = 0.61) or unplanned visit (15.4% vs 18.8%, p = 1.0). Group B had a higher prevalence of MiniACE® button placed through the appendix vs. Malone (42.8% vs 12.5%, p = 0.10). Conclusions Our expedited post-op protocol decreased length of stay without other significant adverse clinical sequelae. Level of evidence Retrospective Comparative Study, Level III.

Zusammenfassung. Ausscheidungsstörungen sind häufige Störungen des Kindesalters. Es können drei übergeordnete Gruppen unterschieden werden: die Enuresis nocturna, das Einnässen tagsüber und die Enkopresis oder Stuhlinkontinenz. Inzwischen sind viele Subgruppen identifiziert, die sich exakt diagnostizieren lassen. Das Ziel dieser Übersicht ist es, die Klassifikationsvorschläge der ICD-11 kritisch darzustellen. Die Definitionen der Enuresis nach ICD-11 werden mit den Störungsbildern der Enuresis nocturna und der funktionellen Harninkontinenz tags nach ICCS verglichen. Die Enkopresis nach ICD-11 wird den Rome-IV-Definitionen der funktionellen Obstipation und der nicht-retentiven Stuhlinkontinenz gegenübergestellt. Es wird dabei deutlich, dass die ICD-11 nicht dem aktuellen Forschungsstand entspricht, dass sie für die klinische Praxis keine therapieleitenden Diagnosen liefert und dass sie für die Forschung nicht genau genug ist. Deshalb sind die Klassifikationssysteme der ICCS und der Rome-IV in Klinik und Forschung vorzuziehen.

Avoidant restrictive food intake disorder (ARFID) was recently characterized, according to the DSM-5 classification, as a feeding and eating disorder (FED). However, ARFID remains poorly known by most pediatricians, but also by psychiatrists and primary care professionals. Despite the fact that patients with ARFID generally have a higher BMI than patients with anorexia nervosa, our purpose was to highlight the fact that they may present severe nutritional deficiencies and major somatic complications when the diagnosis is delayed. We describe here a case of a 16-year-old boy who presented with severe undernutrition (BMI = 11.5) leading to Ogilvie’s syndrome, which resolved with enteral refeeding. Because of undernutrition, very bad dental condition, and encopresis, some physicians wrongly suspected child neglect, but retrospective analysis of his personal history revealed a long-term FED and sensory specificities that led to the final diagnosis of an ARFID–autism spectrum disorder (ASD) association. A literature review was conducted on the ARFID somatic complications. The training of health professionals in the clinical forms of pediatric FED, including ARFID, is necessary, to promote early diagnosis and prevent poor nutritional outcomes. In this case the association of ARFID–ASD and the delay in access to specialized care favored by the disadvantaged social environment led to severe gastrointestinal complications. V, descriptive study.

Introduction and objectives: Anorectal manometry is a test that evaluates the function of the rectum,but also the anus. It is useful for the diagnosis of several conditions like fecal incontinence and constipation.In children these tests are being increasingly used for all ages.The aim of this study was to determine the benefit of anorectal manometry in children and to report our experience. Material and Methods:Over a period of four years, 273children that underwent anorectal manometry were included in the study,their data and tests results were analyzed. Results:Out of 273 patients included,68,5% were boys and 31,5% were girls.The mean age was 9 years.154patients(51,6%) had Fecal incontinence(Group1),75children(27,5%) had chronic constipation(Group2),and both of them(Group3) were reported in 37children(13,6%).An awake manometry was performed in 248children(91%) however this test under sedation allowed us the exclusion of Hirschsprung’s disease in 21children(84%).In group1, 25%patients had bad anal contraction.In groupe3, 21,6%children had bad anal contraction.The statistical analysis showed a significant difference in age(p=0.022) and resting pressure(p=0.050) between the three groups.Children with fecal incontinence had a higher rate of dyssynergy,80.2% and 83.8% in groups 1 and 3 respectively compared to 60.4% in patients with chronic constipation(p=0,852) Conclusion:The gold standard for the exploration of children’s terminal constipation and encopresis is the anorectal manometry.It is an important tool to establish diagnosis.In our study, this test allow the exclusion of Hirschsprung’s disease in infants with constipation, in other hand we found a higher rate of dyssynergy in children with fecal incontinence(80%) which had allow us to propose a biofeedback therapy.

Bladder and bowel dysfunction (BBD) is a common yet underdiagnosed paediatric entity that describes lower urinary tract symptoms (LUTS) accompanied by abnormal bowel patterns manifested as constipation and/or encopresis. LUTS usually manifest as urgency, urinary frequency, incontinence, and urinary tract infections (UTI). Despite increasing recognition of BBD as a risk factor for long-term urinary tract problems including recurrent UTI, vesicoureteral reflux, and renal scarring, the mechanisms underlying BBD have been unclear, and treatment remains empirical. We investigated how constipation affects the lower urinary tract function using a juvenile murine model of functional constipation. Following four days of functional constipation, animals developed LUTS including urinary frequency and detrusor overactivity evaluated by awake cystometry. Physiological examination of detrusor function in vitro using isolated bladder strips, demonstrated a significant increase in spontaneous contractions without affecting contractile force in response to electrical field stimulation, carbachol, and KCl. A significant upregulation of serotonin receptors, Htr2a and Htr2c, was observed in the bladders from mice with constipation, paralleled with augmented spontaneous contractions after pre-incubation of the bladder strips with 0.5 µM of serotonin. These results suggest that constipation induced detrusor overactivity and increased excitatory serotonin receptor activation in the urinary bladder, which contributes to the development of BBD.

Introduction: Carbon monoxide (CO) poisoning is a prevalent lethal condition. The clinical feature of this type of poisoning varies from headache and nausea to more severe conditions. After recovery from the acute intoxication, neurological or behavioral problems may emerge. In 3%-40% of cases, delayed neuropsychiatric syndrome (DNS) in post CO poisoning, generally develops within few weeks after a preliminary remission from acute poisoning. Case Presentation: We report a patient with relatively suitable premorbid. He was admitted to the hospital with fire burning, co poisoning and discharged home with good general conditions and mental status by receiving normal baric oxygen 100%. later in post-operative management of skin graft he developed a fulminant neurological deficit by impaired memory and concentration, loosening of association, disorientation to place, time and person, agitation, aggression, mood labiality, urinary incontinency and encopresis, slow psychomotor retardation, false and approximate answers to questions, auditory and visual hallucination, staring and inappropriate laughing. As the patient was not responsive to neurological treatment, he was referred to psychiatric service. DNS in this patient resolved gradually during a short period of psychopharmacotherapy and supportive psychotherapy. Conclusion: CO poisoning may lead to neuropsychiatric sequel and neuroimaging changes which could be reversible.

After clinical and neurophysiological examinations of 22 patients with developmental anomalies of the rectum and anus, who suffered of fecal incontinence of type III and who were operated in the Vladimirsky Moscow Region Clinical Institute, a modern approach to the diagnostics of neuromuscular disorders has been proposed. A particular attention was paid to the sacral plexus and its branches. A detailed examination of the sexual nerve and its functions was made using a St. Mark disposable rectal electrode. The optimal evaluation of motor potentials from the thigh muscles under transrectal stimulation of the sacral plexus was made; findings of EMG diagnostics were compared too. The researchers backgrounded an optimal modality for treating this pathology: not only surgical tactics, but also patient’s reserve capabilities in restoring lost functions using EMG biological feedback.

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

Objective: To identify and describe the protocols and clinical outcomes of urotherapy interventions in children and adolescents with bladder bowel dysfunction. Method: Systematic review carried out in June 2018 on Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica dataBASE (EMBASE), Scientific Electronic Library Online (SciELO), Cochrane Library, and PsycInfo databases. Clinical trials and quasi‐experimental studies carried out in the last ten years in children and/or adolescents with bladder and bowel symptoms and application of at least one component of urotherapy were included. Results: Thirteen clinical trials and one quasi‐experimental study were included, with moderate methodological quality. The heterogeneity of the samples and of the methodological design of the articles prevented the performance of a meta‐analysis. The descriptive analysis through simple percentages showed symptom reduction and improvement of uroflowmetry parameters. The identified urotherapy components were: educational guidance, water intake, caffeine reduction, adequate voiding position, pelvic floor training, programmed urination, and constipation control/management. Conclusion: This review indicates positive results in terms of symptom reduction and uroflowmetry parameter improvement with standard urotherapy as the first line of treatment for children and adolescents with bladder bowel dysfunction. It is recommended that future studies bring contributions regarding the frequency, number, and time of urotherapy consultations. Resumo: Objetivo: Identificar e descrever os protocolos e desfechos clínicos das intervenções de uroterapia em crianças e adolescentes com disfunção vesical e intestinal. Método: Revisão sistemática realizada em junho de 2018 nas bases Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica dataBASE (EMBASE), Scientific Electronic Library Online (SciELO), Cochrane Library e PsycInfo. Foram incluídos ensaios clínicos e estudos quase‐experimentais dos últimos 10 anos, em crianças e/ou adolescentes com sintoma urinário e intestinal e aplicação de no mínimo um componente de uroterapia. Resultados: 13 ensaios clínicos e 1 estudo quase‐experimental foram incluídos, sendo a qualidade metodológica moderada. A heterogeneidade da amostra e de delineamento metodológico dos artigos impediu a realização de meta‐análise. A análise descritiva por meio de percentual simples demonstrou redução dos sintomas e melhora dos parâmetros de urofluxometria. Os componentes de uroterapia identificados foram: orientação educacional, ingestão hídrica, redução de cafeína, posicionamento adequado para eliminação, treinamento do assoalho pélvico, micção programada e controle/manejo da constipação. Conclusão: Esta revisão sinaliza resultados positivos em termos de redução de sintomas e melhora nos parâmetros de urofluxometria com aplicação de uroterapia padrão como primeira linha de tratamento nos casos de crianças e adolescentes com disfunção vesical e intestinal. Recomenda‐se que estudos futuros tragam contribuições no que tange a frequência, número e tempo para as consultas de uroterapia. Keywords: Bladder bowel dysfunction, Urotherapy, Behavior therapy, Dysfunctional elimination syndrome, Dysfunctional voiding, Child, Palavras‐chave: Disfunção vesical e intestinal, Uroterapia, Terapia comportamental, Síndrome de eliminação disfuncional, Micção disfuncional, Criança

The aim of the study was to assess the impact of bowel management on the quality of life in children with spina bifida with overactive bladder and detrusor sphincter dyssynergia.The research was carried out over the 2014-2017 period, during which 70 patients with spina bifida with overactive bladder and detrusor sphincter dyssynergia were observed. The first group (group 1) consisted of 35 patients who were administered bowel management combined with anticholinergic medication therapy and CIC. The second group (group 2) consisted of 35 patients who were treated only with anticholinergic medication therapy and CIC. Bowel management included daily enema, laxative application, and a special diet, with a view of treating constipation and fecal incontinence that was estimated on the basis of Roma III criteria, the echosonographically determined transversal rectal diameter, and encopresis frequency. The effects of the administered bowel management on urinary incontinence were estimated on the basis of the average dry interval between two CICs. Regarding the quality of life, a KINDL questionnaire was used for children and parents to determine the overall quality of life, but also the various aspects of the quality of children's life (physical well-being, emotional well-being, self-confidence, family, friends, school, disease). The test score ranges from 0 to 100, where 0 is the lowest and 100 denotes the highest quality of life. The follow-up period of every patient was one year.At baseline, there was no significant difference between the groups regarding demographic and clinical features (p 0.05). After one year, treatment by bowel management demonstrated significant improvement for both fecal constipation/incontinence and urinary incontinence (p 0.001). The bowel management group showed improved overall quality of life in contrast to the group without bowel management 88.9 ± 7.1 vs. 55.4 ± 11.4 (p 0.001, assessed by parents) and 84.5 ± 8.9 vs. 53.4 ± 12.5 (p 0.001, assessed by children), respectively. Moreover, the positive impact of bowel management on quality of life was confirmed for all domains of the quality of life (physical well-being, emotional well-being, self-confidence, family, friends, school, disease), (p 0.001 for all), both by the parents' and the children's assessment.Administering bowel management considerably alleviates the symptoms of fecal and urinary incontinence and considerably improves the quality of life. Bowel management should be considered as an integral part of treatment of children with spina bifida.

У статті показано ефективність застосування внутрішньосфінктерної електростимуляції при функціональних енкопрезах у дітей за допомогою спеціального електрода. Відзначено значно більшу ефективність її застосування при істинному енкопрезі порівняно з несправжнім енкопрезом.

To date, due to the increasing prevalence of psychiatric diseases, the use of antipsychotic drugs has expanded. One of the proven side effects of these drugs is incontinence. Treatment of this complication improves the quality of life in these patients, increases self-confidence, and betters cope with their psychiatric illness. The exact mechanism of this side effect is not fully understood, but various methods have been used experimentally to deal with it. Strategies such as behavior therapy, discontinuation or change of drugs, reducing the dose of drugs, and adding drugs with less incontinence have been used. Each of these methods and studies has different results that need to be summarized to make optimal use of them. Since most of these reports are case reports with a low statistical population, our study has systematically reviewed these studies to find a comprehensive model to deal with this complication.

espanolResumen Introduccion: La encopresis es la incontinencia fecal repetitiva y espontanea en mayores de 4 anos, relacionada con estrenimiento cronico y disfuncion de la eliminacion del producto fecal, debido a anomalias neurologicas como la ausencia de neuronas entericas en el colon en la enfermedad de Hirschsprung; a causa de la impactacion fecal, el intestino grueso, aumenta tanto de tamano como de longitud, llamandose Dolico megacolon. El objetivo es presentar el caso clinico de un nino en etapa escolar con encopresis. Presentacion del caso: Nino de 7 anos, acude por incontinencia fecal repetitiva y espontanea asociada a estrenimiento cronico, es diagnosticado por medio de biopsia de la linea pectinea, se reporta presencia de 1-2 celulas ganglionares y es tratado por enfermedad de Hirschprung. El manejo clinico con dieta blanda, polietilenglicol, agua de zen e irrigaciones rectales, con adherencia deficiente; posteriormente, se realiza exeresis de colon descendente, sigma y recto con tecnica de Georgeson, en el postquirurgico se realizan dilataciones con Hegar 18 y se administra metronidazol 220mg/VO/STAT por complicacion postquirurgica. Tras el manejo clinico y quirurgico el paciente mejora evacuando 5 veces al dia. Conclusion: Se concluye que el tratamiento quirurgico fue exitoso, sin embargo, el paciente no acude a los controles postquirurgicos; presentandose nuevamente al servicio, por complicaciones como fisuras anales y rectorragia. EnglishAbstract: Introduction: Encopresis is repetitive and spontaneous fecal incontinence in people older than 4 years, related to chronic constipation and dysfunction of the elimination of the fecal product, due to neurological abnormalities such as the absence of enteric neurons in the colon, Hirschsprung's disease; due to fecal impaction, the large intestine increases both in size and in length, being called Dolico megacolon. The objective is to present the clinical case of a school-age child with encopresis. Case presentation: A 7-year-old boy presented for repetitive and spontaneous fecal incontinence associated with chronic constipation, was diagnosed by biopsy of the pectineal line, the presence of 1-2 ganglion cells was reported and treated for Hirschprung's disease. Clinical management with soft diet, polyethylene glycol, zen water, and rectal irrigations, with poor adherence; Subsequently, the descending colon, sigmoid, and rectum were excised with the Georgeson technique; postoperatively, dilations were performed with Hegar 18, and 220mg / PO / STAT metronidazole was administered due to postoperative complications. After clinical and surgical management, the patient improves by evacuating 5 times a day. Conclusion: It is concluded that the surgical treatment was successful, however, the patient does not attend post-surgical controls; he presented himself again for the service, due to complications such as anal fissures and rectorrhagia

Purpose To describe the implementation and effectiveness of a multimodal therapeutic approach used to successfully treat a child with encopresis. Summary of key points The child demonstrated chronic constipation, poor pelvic floor muscle awareness, weakness, and incoordination during voiding. He participated in 8 sessions of physical therapy intervention including pelvic floor muscle awareness, strengthening and coordination exercises, behavioral adaptations, diet modification, and use of media, art, and interactive visualization activities. Conclusions The child improved pelvic floor muscle strength and coordination and became fully continent of bowel in home and community settings. What this case adds to evidence-based practice This case report demonstrates that pediatric age-appropriate educational and motivational tools (media, art, and interactive visualization activities) are readily available, economical, and effective when used in conjunction with current practice to decrease impairments and improve active participation and compliance during treatment of retentive encopresis in the pediatric population.

Constipation is a common problem in children. Although most children respond to conventional treatment, symptoms persist in a minority. For children with refractory constipation, anorectal and colonic manometry testing can identify a rectal evacuation disorder or colonic motility disorder and guide subsequent management. Novel medications used in adults with constipation are beginning to be used in children, with promising results. Biofeedback therapy and anal sphincter botulinum toxin injection can be considered for children with a rectal evacuation disorder. Surgical management of constipation includes the use of antegrade continence enemas, sacral nerve stimulation, and colonic resection.

Background . The gastrointestinal polypeptide YY has an inhibitory effect on the colon motility, which can provoke constipation. The role of this peptide in the development of chronic constipation in children remains uninvestigated. Objective. Our aim was to determine the serum concentration of peptide YY in children with chronic constipation. Methods . A cross-sectional study included children aged 4–14 years with chronic constipation, who have been observed in the gastroenterology unit of the paediatric clinical hospital from March 2014 to September 2015. The control group was formed from healthy children. The diagnosis of chronic constipation was established based on the Rome criteria (2016). The blood serum level of peptide YY was determined by enzyme immunoassay after collecting serum samples from all study participants. Results . The study included 47 patients with chronic constipation (boys 62%; median age — 8 years) and 20 healthy children (boys 50%; median age — 7.5 years, compared with the main group p = 0.445). It has been found that children with chronic constipation had a lower blood serum concentration of peptide YY than healthy children: the median (25th; 75th percentile) was 0.68 (0.24; 1.43) and 2.34 (1.41; 3.35) ng/ml, respectively (p < 0.001). The level of peptide YY in the group of children with chronic constipation was not related to gender, age; the presence of colonoptosis, colonic/enteric reflux; the duration of chronic constipation, as well as to the occurrence of complications such as encopresis and colitis. Conclusion . Low blood serum levels of peptide YY were detected in children with chronic constipation.

Background Sexual victimisation is an important problem that affects millions of people around the world, especially those with some kind of disability. The aim of this study was to determine the prevalence of self-reported and documented sexual abuse in people with mild or moderate intellectual disability and to analyse the sequelae that such experiences can have on their psychosocial health. Methods The sample consisted of 360 adults (50% men and 50% women) between 18 and 55 years of age (M = 39.87; standard deviation = 10.55). Results The prevalence of sexual abuse is 6.10% when it is self-reported (9.4% in women and 2.8% in men) and 28.6% when it is reported by professionals (27.8% in women and 29.4% in men). People who self-report cases of abuse present poorer quality of life, more negative attitudes towards sex and a lower capacity to identify situations that entail a risk of sexual abuse. Individuals who have suffered documented cases of abuse are more likely to present encopresis, social isolation, self-harm and a higher number of suicide attempts. Conclusions Our results evidence the need to have access to all sources of information so as to be able to obtain prevalence figures that match the real situation and to perform a proper analysis of the sequelae.

Background: Constipation is the most common childhood condition occurring in about 3% of children. Patients who have intractable idiopathic or functional constipation (FC) with pseudo encopresis that is unresponsive to bowel management program with no underlying organic cause constitutes a serious medicosocial problem in the pediatric age group. Objective: Evaluation of effectiveness of sigmoidectomy with partial proctectomy in solving the problem of intractable idiopathic constipation in children with megarectosigmoid. Patient and Methods: This was a Prospective case series study for evaluation of the effect of sigmoid resection with partial proctectomy in improving children with intractable idiopathic constipation with megarectosigmoid. The study was conducted on 20 patients. That was selected from more than 250 of idiopathic constipation children. All patients were operated at the Pediatric Surgery Department, Al-Azhar University Hospitals. The study was of 30 months duration(Feb 2018-July 2020). We used Rome III criteria and Pediatric Incontinence Constipation Score to evaluate constipation and incontinence pre and post operatively. Detailed history taking, clinical examination(including rectal examination) and investigations(including laboratory tests, radiologic examinations, rectal biopsy). Results: The study included 20 patients, 7 females and 13 males. Patients ages ranged from 4-13 years(mean=7.2). Constipation was the main complain in all patients followed by soiling. Sigmoidectomy with partial proctectomy recorded 90% success in improving constipation and consequently soiling; the results of Sigmoidectomy without partial proctectomy was disappointing. Conclusion: Rectosigmoidectomy is the best surgical management for the children suffering from intractable functional constipation with Megarectosigmoid, Partial removal of the rectum is very crucial in improving results.

PURPOSE: Currently, there is a paucity of studies on the prevalence of Elimination Disorders among Iranian children and adolescents. Due to the ongoing need to monitor the health status of these children and adolescents, the present study aims to investigate the prevalence of Elimination Disorders and comorbid disorders in Iranian children and adolescents. METHODS: In this cross-sectional study, 29,781 children and adolescents age 6 to 18 years old were selected and studied from all the provinces in Iran. The sampling was carried out by employing a multistage cluster sampling method, and several clinical psychologists using semi-structured interviews collected the data. Furthermore, clinical psychologists collected demographic information (including information about gender, age, place of residence, education level, and parental education level). The collected data were analyzed using SPSS version 20. RESULTS: Generally, the prevalence of Elimination Disorders was found to be 5.4 covering both enuresis (p= 5.4, 95 CI = 5.1-5.7) and encopresis (p= 0.13, 95 CI = 0.09-0.2). The total prevalence of comorbid disorders was 38, and among the comorbid disorders, Attention Deficit Hyperactivity Disorder (ADHD) (p= 11, 95 CI = 9.5-12.7) and Separation Anxiety (p= 10.6, 95 CI = 9.1-12.2) were the most prevalent. CONCLUSION: The prevalence of Elimination Disorders in Iranian children and adolescents is moderate compared to similar studies elsewhere. As for comorbid disorders, ADHD and Separation Anxiety were found to be the most prevalent disorders. Since Elimination Disorders coexist with psychiatric disorders in children, further studies of these comorbidities may give better insight into the treatment and prognosis of Elimination Disorders. © 2021 - IOS Press. All rights reserved.

Aims Tuberous sclerosis complex (TSC) is a multisystem genetic disorder caused by a mutation in the TSC1 or TSC2 gene with a broad spectrum of physical and psychological manifestations. The aim of the study was to examine incontinence, psychological problems, and adaptive behavior skills in patients with TSC. Methods Through a worldwide TSC support group, 26 children (4-17 years) and 15 adults (18-50 years) with TSC were recruited (38.1% male, mean age 16.4 years). Parents or care-givers completed the Developmental Behavior Checklist (DBC), the Parental Questionnaire: Enuresis/urinary Incontinence, and the Vineland Adaptive Behavior Scales (3rd edition). Results A total of 60.0% of the participants had nocturnal enuresis (NE), 51.3% daytime urinary incontinence (DUI) and 52.4% fecal incontinence (FI). 65.4% of children and 50.0% of adults had a clinically relevant DBC score. Psychological symptoms were associated with at least one subtype of incontinence. The mean adaptive behavior composite (ABC) score of the patients was 57.2 (SD = 26.1), with 38.1% in the average or below-average range (IQ >70), 26.2% with a mild, 11.9% with a moderate and 23.8% with a severe/profound intellectual disability. The incontinence rate was significantly higher in the groups with a lower ABC score. Conclusion A substantial proportion of patients with TSC are affected by incontinence and psychological symptoms. Incontinence was higher in persons with lower adaptive skills and those with at least one type of incontinence showed a significantly higher DBC score. As incontinence and psychological problems affect daily functioning and well-being, assessment, and treatment are recommended.

Hirschsprung disease (HD) is characterized by a variable amount of aganlionosis of the bowel. Enterocolitis both pre-and postoperative requires irrigation and treatment. Following an operation for HD, children should thrive. Recurrent episodes of obstruction require workup. Functional constipation is a common problem seen by pediatric surgeons following failure of medical management. Following workup, motility testing may help determine medical and surgical management.

Besides the well-known four categories of ADHD associated conditions, disruptive behavior disorders, anxiety and mood disorders, learning disorders and autism, there are a number of other less commonly emphasized conditions that are frequently seen and impact those with ADHD. These include sleep disorders, enuresis and encopresis, eating disorders and obesity, obsessive internet use, gaming and gambling, substance abuse and other risky behaviors. It is vital to include evaluation for all of these conditions as part of an assessment for ADHD, and to provide anticipatory guidance and treatment as part of the ADHD treatment regimen. It is also important to understand and recognize the different problems that may present at different stages of life. Each of these conditions comes with treatment measures that are effective, and so awareness and monitoring for problems as they arise can greatly improve outcomes.

Background: Non-neurogenic urinary and fecal incontinence (UI, FI) affects approximately 6% of North American children with 1% of cases becoming refractory (nonresponsive to standard therapies). Incontinence has major potential long-term physiological and psychological implications for patients and their families. While Sacral Neuromodulation (SNM) and Transcutaneous Nerve Stimulation (TENS) are alternative therapies available for the treatment of refractory UI/FI, these are not approved for use in children in Canada. The present study assessed participants' perception of current treatments, incontinence burden, and attitudes toward novel therapies in a single pediatric institution. Methods: Multiple validated questionnaires including Dysfunctional Voiding Scoring System (DVSS), Bristol Stool Chart (BSC), Pediatric Incontinence measurement (PinQ), and Time-Driven Activity Based Costing were used to perform a needs assessment for patients with non-neurogenic refractory incontinence, and to determine patients' and caregivers' attitudes toward alternative therapies. Results: 75% of patients and 89% of caregivers reported a moderate to severe impact of incontinence on QoL with diminished social interactions among the primary concerns. Caregivers were frustrated with current treatments and were open to trying alternative therapies (SNM and TENS), which, at least in the case of SNM, seems to be less expensive, possibly less burdensome and more effective than current surgical options. Conclusion: Pediatric refractory UI/FI has a large impact on patients' and caregivers' QoL and alternative therapies with the potential to improve QoL of patients and caregivers should be further investigated as a substitute for surgery.

Functional constipation is a common childhood problem, with a prevalence of approximately 3% worldwide. The aim of the study was to compare the efficacy of polyethylene glycol (PEG) 3350 and lactulose in the treatment of pediatric functional constipation. A total of 100 subjects with functional constipation were enrolled and centrally randomized to receive PEG 3350 (0.7–1.5 mg/kg/day) or lactulose (0.7–2.0 g/kg/day). There was a significant increase in median (min, max) stool frequency within 1 week in the PEG 3350 group as compared to the lactulose group (1 [0, 3] to 8 [3, 39] vs. 1 [0, 3] to 7 [1, 17]) (p-value < 0.01). The trend was maintained at week 2, week 3 (p-value < 0.01), and week 4 (p-value = 0.05) with the PEG 3350 group reporting higher weekly median stool frequency than the lactulose group. The PEG group reported significant reduction in painful bowel movements from 68.8% subjects at baseline to 43.8% at the end of first week, whereas the lactulose group reported an increase from 48.9% to 73.3% (p-value = 0.05). Other parameters of constipation, i.e. straining, large diameter stool, and large fecal mass as reported subjectively by parents, significantly decreased from baseline to the end of the study in the PEG 3350 arm compared to those in the lactulose arm. At the end of week 4, there was a statistically significant reduction in all the ROME IV–defined criteria between the two groups. This study proved that the PEG 3350 treatment group had early symptom relief and significant improvement compared to the lactulose group in pediatric functional constipation. Clinical Trials Registry India (CTRI/2018/01/011061)

Enuresis and encopresis can be stressful for children and parents. We investigated the comorbid psychiatric disorders and the emotional and behavioral symptoms associated with elimination disorders. A total of 97 children and adolescents (aged 4-17 years) with an elimination disorder participated in this study. The elimination disorder group consisted of three subgroups: 50 subjects with enuresis nocturna, 26 with encopresis, and 21 subjects with enuresis+encopresis. The control group with no elimination disorder comprised 50 healthy subjects. All children were interviewed by a child and adolescent psychiatrist. Comorbid psychiatric disorders were assessed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version (K-SADS-PL). Parents completed the Strengths and Difficulties Questionnaire. The most common diagnosis was attention-deficit/hyperactivity disorder, followed by oppositional defiant disorder. The highest rate of psychiatric comorbidity was observed in the enuresis+encopresis subgroup, followed by the enuresis nocturna and encopresis subgroups. All the subgroups had higher total difficulties scores than the control group. Screening for psychiatric disorders should be performed for all children with incontinence.

This chapter describes appropriate developmental expectations for toileting based on normative child development. Recommendations for initiating toilet training are provided. Common problems associated with toileting (constipation, encopresis, and enuresis) are identified as the prevalence and etiology of these conditions. Evidence-based medical treatment and behavioral health intervention for these problems are discussed. Evidence-based strategies for the practicing clinician are provided. Psychiatric comorbidities and both short- and long-term outcomes are identified.

Purpose A protocol to treat idiopathic constipation is presented. Methods A contrast enema is performed in every patient and, when indicated, patients are initially submitted to a "clean out" protocol. All patients are started on a Senna-based laxative. The initial dosage is empirically determined and adjusted daily, during a one week period, based on history and abdominal radiographs, until the amount of Senna that empties the colon is reached. The management is considered successful when patients empty their colon daily and stop soiling. If the laxatives dose provokes abdominal cramping, distension, and vomiting, without producing bowel movements, patients are considered nonmanageable. Results From 2005 to 2012, 215 patients were treated. 121 (56%) were males. The average age was 8.2years (range: 1–20). 160 patients (74%) presented encopresis. 67 patients (32%) needed a clean out. After one week, 181 patients (84%) achieved successful management, with an average Senna dose of 67mg (range: 5–175mg). In 34 patients (16%) the treatment was unsuccessful: 19 were nonmanageable, 3 noncompliant, and 12 continued soiling. At a later follow-up (median: 329days) the success rate for 174 patients was 81%. Conclusion We designed a successful protocol to manage idiopathic constipation. The key points are clean out before starting laxatives, individual adjustments of laxative, and radiological monitoring of colonic emptying. Treatment study Level IV.

Bladder and bowel dysfunction is a common pediatric disorder that involves lower urinary tract symptoms (LUTS) as well as constipation and/or encopresis. Effective treatment of constipation in these patients leads to resolution or improvement of urinary symptoms in the majority of cases. Because many of these children initially present to the urologist with the primary complaint of LUTS, it is important for the consulting specialist to be well-versed on the topic of constipation. This review aims to provide an evidence-based guide on the evaluation and management of constipation in children. Recent papers have improved our knowledge on the utilization of interventions such as antegrade continence enemas and sacral nerve stimulation for more recalcitrant cases of constipation. Although there have been limited advancements in the use of pharmacologic therapies for the treatment of constipation in children, it is hoped that newer therapeutic agents proven effective for adult constipation will gain pediatric use over time. Present therapy for constipation in BBD is effective for the majority of patients. There is promise for further improvement in treatment options in the near future.

Introduction Evidence suggests that urinary and fecal incontinence and abnormal voiding and defecation dynamics are different manifestations of the same syndrome. This article reports the success of an innovative program for care of children with incontinence and dysfunctional elimination. This program is innovative because it is the first to combine subspecialty services (urology, gastroenterology, and psychiatry) in a single point of care for this population and the first reported independent nurse practitioner–run specialty referral practice in a free-standing pediatric ambulatory subspecialty setting. Currently, services for affected children are siloed in the aforementioned subspecialties, fragmenting care. Methods Retrospective data on financial, patient satisfaction, and patient referral base were compiled to assess this program. Results Analysis indicates that this model is fiscally sound, has similar or higher patient satisfaction scores when measured against physician-run subspecialty clinics, and has an extensive geographic referral base in the absence of marketing. Discussion This model has potential transformative significance: (a) the impact of children achieving continence cannot be underestimated, (b) configuration of services that cross traditional subspecialty boundaries may have broader application to other populations, and (c) demonstration of effectiveness of non-physician provider reconfiguration of health care delivery in subspecialty practice may extend to the care of other populations.

AIM To describe the prevalence and consultation characteristics of enuresis in Australian paediatric practice and assess for changes over a period of 5 years. METHODS Data collected prospectively by paediatricians (outpatient settings) in 2008 and 2013, as part of the Children Attending Paediatricians Study. Consultations on children aged 5 years or over were included. Consultations in each cohort (2008 and 2013) categorised as either listing or not listing enuresis. Characteristics of the 'enuresis' versus 'non-enuresis' subgroup in each cohort were compared as were the enuresis subgroups 2008 versus 2013. RESULTS Of 4175 and 4181 consultations in 2008 and 2013, enuresis was reported in 178 (4.3% - 2008) and 193 (4.6% - 2013). Constipation and encopresis were more prevalent in the enuresis versus non-enuresis subgroups (46 (25.8%) vs. 136 (3.4%) for constipation and 25 (14%) vs. 65 (1.6%) for encopresis in 2008; 52 (26.9%) vs. 160 (4%) for constipation and 25 (13%) vs. 78 (2%) for encopresis in 2013, both P < 0.001). The enuresis subgroup had more referrals to multidisciplinary teams (19 (10.7%) vs. 148 (3.7%) - 2008 and 21 (10.9%) vs. 163 (4.1%) - 2013, both P < 0.001) and allied health professionals (29 (16.3%) vs. 230 (5.8%) - 2008; 27 (14%) vs. 178 (4.5%) - 2013, both P < 0.001). CONCLUSION The overall frequency of presentation of children for management of enuresis was low. Prevalence/Consultation characteristics of enuresis were comparable over 5 years. Constipation and encopresis were significantly more prevalent in the enuresis subgroups.

Background The role of endoscopic ultrasound (EUS) in the management of pancreatobiliary and digestive diseases is well established in adults, but it remains limited in children. The aim of this study was to evaluate the feasibility, safety, and clinical impact of EUS use in children. Methods This is a retrospective analysis of a prospectively acquired database of consecutive pediatric (< 18 years) patients presenting an indication for EUS for pancreatobiliary and gastrointestinal disorders. Results Between January 2010 and January 2016, 47 procedures were performed in 40 children (mean age of 15.1 ± 4.7 years; range 3–18). The majority of EUS (n = 32; 68.1%) were performed for pancreatobiliary and upper gastrointestinal pathologies, including suspected common bile duct stones (CBDs), acute biliary pancreatitis, recurrent/chronic pancreatitis, cystic pancreatic mass, recurrent hypoglycemia, duodenal polyp, gastric submucosal lesion, and perigastric abscess. In only 2 out of 18 children with suspected CBDs or acute biliary pancreatitis, EUS confirmed CBDs. EUS-guided fine needle aspiration was performed in 3 (6.4%) patients. Fifteen (31.9%) procedures were performed for lower gastrointestinal tract disorders, including suspected anal Crohn’s disease, fecal incontinence, and encopresis. Overall, EUS had a significant impact on the subsequent clinical management in 87.2% of patients. Conclusion The present findings were consistent with results observed in the current relevant literature and support EUS as a safe and feasible diagnostic and therapeutic tool, which yields a significant clinical impact in children with pancreatobiliary and gastrointestinal disorders.

Background The role of surgery in treating children with functional constipation (FC) is controversial, because of the efficacy of bowel management programs. This case series is comprised of failures: 43 children, spanning 25 years' practice, who had megarectosigmoid (MRS) and unremitting constipation. Purpose To determine whether these children were helped by surgery, and to contribute to formulating a standard of care for children with megarectum (MR) and/or redundancy of the sigmoid colon (MS) who fail medical management. Method We describe our selection criteria and the procedures we utilized – mucosal proctectomy and endorectal pull-through (MP) or sigmoidectomy (SE) with colorectal anastomosis at the peritoneal reflection. The internet (social media) allowed us to contact most of these patients and obtain extremely long follow-up data. Results 30/43 patients had MP and 13/43 had SE. Follow-up was obtained in 83% MP and 70% SE patients. 60% of MP and 78% of SE patients reported regular evacuations and no soiling. 20% MP patients had occasional urgency or soiling or episodic constipation. 12% MP and 22% SE patients required antegrade continence enemas (ACE) or scheduled cathartics and/or stool softeners. 4% MP had no appreciable benefit, frequent loose stools and soiling, presumably from encopresis. Conclusion MR is characterized by diminished sensation, poor compliance and defective contractility. Patients with MR do better with MP, which effectively removes the entire rectum versus SE, where normal caliber colon is anastomosed to MR at the peritoneal reflection; furthermore, MP reliably preserves continence; whereas total proctectomy (trans-anal or trans-abdominal) may cause incontinence., Highlights • Intestinal peristalsis stagnates in a dilated segment. • Megarectosigmoid (MRS) may present during infancy or later in life. • It may occur in association with anorectal malformations or as an isolated abnormality. • Unlike dilatation secondary to outlet dysfunction, MRS persists even after a diverting colostomy. • MRS does not respond to bowel management programs. • Intestinal peristalsis improves following extirpation of MRS.

Summary Background Bladder and bowel dysfunction (BBD) is a common pediatric problem that describes a constellation of lower urinary tract symptoms associated with constipation and/or encopresis. Its association with neurodevelopmental and psychiatric (NDP) problems is not well understood. Objectives Our primary aim was to identify pre-existing NDP disorders in children with BBD. Secondarily, we aimed to screen for new behavioral problems and evaluate the association between bladder or bowel symptoms and behaviors symptoms. Methods A cross sectional study was conducted in urology clinics. New patients referred for BBD between 4 and 17 years old were recruited and completed: a demographics survey, Dysfunctional Voiding Score System questionnaire, assessment of bowel movements with the Bristol Stool Scale, and Strength and Difficulties questionnaire (SDQ). Those with known spinal dysraphism were excluded. SDQ scores were evaluated for abnormal screens in different subscales and total difficulties scores. Pearson correlation analyses were conducted for association. Results We included 61 participants (age 9.5 ± 4.1 years), including 33 females and 28 males. One or more pre-existing NDP disorder(s) was reported in 14 (23%) children; most commonly being learning disability (43%) and attention deficit hyperactivity disorder (29%). This cohort had more severe BBD symptoms as reflected in DVSS scores. SDQ scores demonstrated that 12 patients without pre-existing NDP diagnoses scored in the clinical range, with hyperactivity as the most common difficulty (6/12; 50%). Conclusions A significant proportion of children with BBD have a comorbid NDP disorder and present with more severe symptomatology. The SDQ can be used as a behavioral screening tool this population for the identification of children who may benefit from formal developmental pediatrics assessment. Summary Table 1 . Comparison between those with and without neuropsychiatric disorder. Prior Neuropsychiatric Disorder No Prior Neuropsychiatric Disorder P value (95% Confidence Interval) Patients 14 (23) 47 (77) – Age 10 (SD = 3.5) 9 (SD = 4) 0.403 (−1.45 to 3.55) Gender Female 6 (43) 27 (43) – Male 8 (57) 20 (57) – DVSS (Mean Total Score) 13 (SD = 6) 9 (SD = 4) 0.018∗ (0.59–6.15) Bristol Stool Scale (Median Score) 3 3 0.791 (−0.50 to 0.66) SDQ (Mean Total Score) 19 (SD = 5.5) 9.6 (SD = 4.7) 0.0001∗ (6.72–12.72)

The term ‘encopresis’, derived from ancient Greek ἐγκόπρησις / egkóprēsis, which means stool, was first introduced in 1926 by Weissenberg to describe the loss of stool in underwear as the faecal equivalent of enuresis. The soiling of underwear is defined as the accidental passage of very small amounts of faeces into underpants. Quantitatively, the content of stool between encopresis and soiling is difficult to determine, and it is especially difficult for parents assess it. Therefore, a new term was adopted – faecal incontinence – that encompasses both encopresis and soiling. Faecal incontinence is defined as the discharge of faeces in socially awkward situations at least once per month in children ≥ 4 years old. In approximately 95% of cases, faecal incontinence in children is not organic in origin, but instead appears as a functional gastrointestinal disorder. In 80% of children with functional faecal incontinence, the symptoms are associated with functional constipation. The remaining 20% of the cases involve no signs of faecal retention and are defined as non-retentive functional faecal incontinence. This paper aims to present the latest findings within this area of paediatric gastroenterology.

Constipation is one of the most common problems evaluated by pediatricians, pediatric gastroenterologist, and pediatric surgeons alike. A clear and concise management algorithm is needed to appropriately treat patients and avoid unnecessary outpatient and emergency department visits. Once organic causes of constipation have been ruled out, treatment should progress in a stepwise fashion until success, defined as daily bowel movements without encopresis or overflow pseudoincontinence. Therapy should begin with diet modification and progress through the use of polyethylene glycol, stimulant laxatives, daily enemas, and even formal inpatient fecal disimpaction. For those patients who fail to successfully evacuate their colons or those who have persistent incontinence secondary to severe constipation, surgical options such as appendicostomy should be explored. Ultimately, we must all accept that constipation can be a severe, life-altering problem which should be addressed with an aggressive management strategy.

Fecal incontinence is a socially debilitating problem for many children. We hypothesized that in selected patients with medically-refractory encopresis, placement of an appendicostomy or cecostomy tube for administration of antegrade continence enemas (ACE) would improve quality of life (QOL).We reviewed all patients with encopresis who underwent appendicostomy or cecostomy placement from 2003 to 2014 at our institution. We contacted subjects' parents by phone and administered 3 surveys: a survey reflecting current stooling habits, a disease-specific QOL survey, and the PedsQL™ QOL survey. QOL surveys were completed twice by parents, once reflecting pre-operative QOL, then again reflecting current QOL. Pre-procedure and post-procedure scores were compared by paired t-test.Ten patients underwent appendicostomy/cecostomy for encopresis. Eight completed phone surveys. All procedures were performed laparoscopically. All patients experienced fecal soiling pre-operatively, whereas 5/8 surveyed patients (63%) noted complete resolution of soiling post-procedure (p0.01). General and disease-specific QOL improved from pre-procedure to post-procedure in the following domains: social habits, physical activity, ability to spend the night elsewhere, feeling, and overall QOL (p0.05). PedsQL™ scores improved significantly in physical functioning, social functioning, and overall functioning (p0.05).Antegrade continence enemas significantly improve quality of life in patients with medically-refractory encopresis, likely related to resolution of soiling.4.

We evaluated whether an animated bladder training video was as effective as standard individual urotherapy in improving bladder/bowel symptoms.Patients 5 to 10 years old who scored greater than 11 on the bladder/bowel Vancouver questionnaire were included in a noninferiority randomized, controlled trial. Children with vesicoureteral reflux, neuropathic bladder, learning disabilities, recent urotherapy or primary nocturnal enuresis were excluded from analysis. Patients were randomly assigned to receive standard urotherapy or watch a bladder training video in clinic using centralized blocked randomization schemes. Bladder/bowel symptoms were evaluated at baseline and 3-month followup by intent to treat analysis. A sample size of 150 patients ensured a 3.5 difference in mean symptomology scores between the groups, which was accepted as the noninferiority margin.Of 539 screened patients 173 (37%) were eligible for study and 150 enrolled. A total of 143 patients (95%) completed the trial, 5 (4%) were lost to followup and 2 (1%) withdrew. Baseline characteristics were similar between the groups. Baseline mean ± SD symptomology scores were 19.9 ± 5.5 for the bladder training video and 19.7 ± 6.0 for standard urotherapy. At 3 months the mean symptomology scores for the bladder training video and standard urotherapy were reduced to 14.4 ± 6.5 and 13.8 ± 6.0, respectively (p = 0.54). The mean difference was 0.6 (95% CI -1.4-2.6). The upper 95% CI limit of 2.6 did not exceed the preset 3.5 noninferiority margin.The bladder training video was not inferior to standard urotherapy in reducing bladder/bowel symptoms in children 5 to 10 years old. The video allows families to have free access to independently review bladder training concepts as often as necessary.

The experience of a work with a group of children with enuresis (six patients) and encopresis (one patient) both of residual-organic origin is analyzed in this article. Work included psychological diagnostic techniques and psychological correction. Psychological diagnostic evaluation was directed to the measurements of different characteristics of sensorimotor reactions, memory, attention and cognitive functions. Functional characteristics of the central nervous system in children with enuresis and encopresis were approximated to those recorded in their healthy peers, while the cognitive functions in present group of children were lower. Psychological correction has included neuropsychological methods, which were aimed at the development of: visual-motor coordination, spatio-temporal organization relations and logic constructions understanding. Based on children's and parent's self-reports and based on medical records also it can be assumed that proposed psychological correction can be effective in enuresis and encopresis in children with similar characteristics, which can be observed. The significance of the functional indices evaluation of the central nervous system by measuring various characteristics of sensorimotor reactions substantiate by results obtained.

CASE: Paul is an 8-year-old boy with a long-standing history of encopresis and enuresis. Potty training was initiated when he was 21/2 years old. At this time, his mother was absent from the home for 6 weeks when she cared for her ill father in a different city. The process of teaching Paul to use the bathroom was described as "inconsistent" due to multiple caretakers. Paul never successfully mastered bowel and bladder control. He continues to wet and soil his clothes on a daily basis at home and school. According to his parents, he does not accept responsibility and comments about his soiling such as, "I didn't do it; someone else must have put it there." One of Paul's teachers commented that she could tell at the beginning of the school day whether he would maintain bowel and bladder control. If he was "agitated and talkative" in the early morning, he would often soil that day. He had a pediatric gastroenterological evaluation at the age of 5 years when he was having daily episodes of stool soiling. Physical examination revealed normal anal tone, normal placement of the anus, and moderate stool in the rectal vault. An abdominal radiograph revealed moderate stool throughout the colon. He was treated with Miralax and instructed to sit on the toilet twice daily. Paul did not respond to these interventions and was diagnosed with "overflow incontinence secondary to stool withholding." When he was taking Miralax, he had a normal barium enema radiograph. He was admitted to the hospital for a cleanout with a polyethylene glycol/electrolyte solution. Although abdominal radiographs demonstrated absence of colonic stool for the following 5 months, he continued to soil his clothing. Play therapy and biofeedback did not change the chronic soiling and wetting pattern. An evaluation at the Continence Clinic resulted in a rigorous program including stooling after each meal, wearing a vibrating watch reminding him to void every 2 hours, drinking 60 ounces of water per day, tracking elimination patterns on a calendar, and a daily laxative (polyethylene glycol). A neuropsychological evaluation revealed a superior aptitude associated with unresolved early childhood issues of self-control, self-care, and frustration tolerance. Family therapy was initiated. However, daily fecal soiling and wetting persisted. Paul was born full-term without prenatal or perinatal complications. He was breast fed for 1 year and described as an easy baby. He achieved motor, social, and language milestone on time. Paul had difficulty with separation and aggression in preschool (e. g., biting). In school, teachers report inattention, fidgetiness, and difficulty following directions. He has been obese since age 3 years; his current body mass index is 29

Objectives The aim of the study was to examine the prevalence of diagnosis and treatment for constipation among children receiving Medicaid and to compare healthcare utilization and spending for constipation among children based on number of complex chronic conditions (CCCs). Methods Retrospective cohort study of 4.9 million children ages 1 to 17 years enrolled in Medicaid from 2009 to 2011 in 10 states in the Truven Marketscan Database. Constipation was identified using International Classification of Disease, 9th revision codes for constipation (564.0x), intestinal impaction (560.3x), or encopresis (307.7). Outpatient and inpatient utilization and spending for constipation were assessed. CCC status was identified using validated methodology. Results A total of 267,188 children (5.4%) were diagnosed with constipation. Total constipation spending was $79.5 million. Outpatient constipation spending was $66.8 million (84.1%) during 406,814 visits, mean spending $120/visit. Among children with constipation, 1363 (0.5%) received inpatient treatment, accounting for $12.2 million (15.4%) of constipation spending, mean spending $7815/hospitalization. Of children hospitalized for constipation, 552 (40.5%) did not have an outpatient visit for constipation before admission. Approximately 6.8% of children in the study had ≥1 CCC; these children accounted for 33.5% of total constipation spending, 70.3% of inpatient constipation spending, and 19.8% of emergency department constipation spending. Constipation prevalence was 11.0% for children with 1 CCC, 16.6% with 2 CCCs, and 27.1% with ≥3 CCCs. Conclusions Although the majority of pediatric constipation treatment occurs in the outpatient setting, inpatient care accounts for a sizable percentage of spending. Children with CCCs have a higher prevalence of constipation and account for a disproportionate amount of constipation healthcare utilization and spending.

Background Opioid use is a significant national crisis impacting individuals struggling with addiction and their families. The majority of individuals who abuse opioids are of child-rearing age, and critical knowledge gaps remain regarding how this abuse impacts their offspring. Fortunately, treatment for opioid use disorders is available. The primary goal of this study was to evaluate both physical and psychiatric diagnoses of children who have at least 1 parent participating in a buprenorphine-assisted treatment program. Methods This retrospective study is based on chart review (January 1, 2010, through June 30, 2018). Children with parents receiving care in a buprenorphine clinic were identified and matched on sex, race, and age in a ratio of 1:5 with controls from the general pediatric clinic population. Data related to health outcomes were extracted from the medical records. Results Compared to controls (n = 120), children of parents receiving buprenorphine-assisted treatment (n = 24) were more likely to have been born premature (odds ratio [OR] = 3.3, P = .035), had jaundice after birth (OR = 2.7, P = .034), had enuresis/encopresis (P < .001), and had been the victims of abuse or neglect (OR = 19.7, P = .0005). Children of parents with opioid use disorders were also more likely to utilize emergency services (ie, being seen in the emergency department for fussiness; OR = 4.0, P = .046) and were less likely to be covered by private insurance compared to state-funded insurance (OR = 0.2, P = .0013). Conclusions Parental opioid use disorder impacts children. More research is needed to better describe long-term effects of treatment of parental opioid use on their offspring and to help design addiction treatment programs to support whole family units.

AIM: Paediatric bladder dysfunction, including daytime urinary incontinence and enuresis, is a common and distressing condition. Unfortunately, children with these symptoms are often on waitlists for several months. This treatment delay may significantly impact upon the child and family unit. This study aimed to quantify waiting times for children who had attended hospital outpatient clinics for symptoms of wetting. METHODS: A retrospective review was undertaken for patients who had been referred to The Royal Children's Hospital, Melbourne outpatient clinics for symptoms of wetting (with/without bowel symptoms). Data regarding the referral and triage pathway, up to the time of the first clinic appointment, were collected. These data were compared to a previous audit conducted in the same setting. RESULTS: A total of 101 clinic attendances were included in this study. The overall waiting time, from receipt of referral to the patient's first clinic attendance, was a median of 181 days (n = 94 valid responses; range 7-695). Wait times for patients with isolated symptoms of wetting were similar to patients with mixed bowel and bladder dysfunction (187 and 171.5 days, respectively). Most patients were triaged to the continence clinic (n = 68), whilst smaller proportions of patients were seen in the encopresis (n = 14), urology (n = 13), general medicine (n = 2), gastroenterology (n = 1) and nurse-led enuresis clinic (n = 3). CONCLUSIONS: The waiting times for patients with wetting generally exceeded 5 months. Alternative pathways for triage need to be explored to manage demand and improve wait times.

Objective To evaluate the characteristics of patients with NE. Design It is a cross-sectional study. Setting During the physical examination, we sought signs and symptoms of voiding disorders and comorbidities with precise questions posed to the patients and their parents. Further, we assessed family history and behavioral characteristics of patients. Analyses were conducted using the Microsoft Excel 2016 program. We used descriptive statistics to describe patients’ information. Patients We recruited 403 children with Noctunal Enuresis (NE) at the Services of Pediatrics, Campus Bio-Medico University Hospital of Rome between June 2013 and July 2018. We rejected 2 children respectively with a renal agenesis and a chromosomopathy and we enrolled 401 patients, 101 girls (25.2%) and 300 boys (74.8%), aged 5–16 years; mean age at first visit 8.8±2.44 years. Of the 401 eligible patients, we counted 327 (81.5%) patients with monosymptomatic NE (MNE) and 74 (18.5%) patients with non-monosymptomatic MNE (N-MNE). In the group of MNE children, 242 (74%) children were boys with mean age at first examination 9.1 years and 85 (26%) were girls with mean age at first examination 7.8 years. In the group of N-MNE children, 58 (78.4%) children were boys with mean age at first examination 9 years and 16 (21.6%) were girls with mean age at first examination 8.4 years. Among the children with MNE, 322 (98.5%) had PMNE and 5 (1.5%) were diagnosed with SMNE. Interventions Not applicable Main outcome measures Signs and symptoms of voiding disorders, comorbidities, family history of NE, behavioral characteristics and school achievement. Results We noticed that heredity, parasomnias, urogenital abnormalities, constipation and innocence heart murmur are correlated to NE. Notably, 53.6% (67/125 children) had paternal heredity, 46.4% (58/125) had maternal heredity; 11.2% (14/125) had both paternal and maternal inheritance. 12/401 (3%) had sleep apnea, 95/401 (23.7%) had somniloquy and 59/401 (14.7%) had bruxism. Children suffered from headaches were 21/401 (5.2%): 112 (27.3%) had family history of headache. 47/300 boys (15.7%) had urogenital-abnormalities: 28/47 (59.6%) children had balanopreputial adhesions. Cutaneous manifestations of spinal dysraphism such as pilonidal dimple, single and deflected intergluteal cleft or double intergluteal cleft were found in 21/401 (5.2%) patients. Encopresis was found in 12/401 (3%) children and 58/401 (14.5%) suffered from constipation. Lastly, a significant percentage of children presented innocent heart murmur (86/401 – 21.4%). Conclusions Our experience demonstrate that there are many comorbidities that influence the prognosis and the response to the therapy in these children.

Objectives Functional constipation in children should be diagnosed in primary care, based on Rome criteria. Management in tertiary care is rarely needed. The aim of this study was to assess the frequency and structure of paediatric patients diagnosed with functional constipation in a tertiary hospital setting. Methods This study enrolled children referred to the paediatric gastroenterologist (PG) at the UHC Zagreb from January 1st 2017 to December 31st 2017 (N=1729). Data on patients was extracted retrospectively from clinical records. The subjects were classified in three age groups: infants and toddlers (0–3 years), children (4–10 years) and adolescents (11–18 years). Descriptive statistics and chi-square test were used, statistical significance was determined as p Results After appropriate evaluation, about 8% of all outpatients seen by the PG at the UHC Zagreb during year 2017 had functional constipation with or without encopresis (7.63% or 132 patients, boys: 56,1% vs girls: 43,9%). Half of the patients were in the age group of 4 to 10 years (66/132 or 50%), about 1/3 was 0 to 3 years old (41/132), and about 1/5 were adolescents (25/132). It was the most common functional gastrointestinal disorder (FGID) (132/328 or 40.24%), both in girls and boys. Also, it was the leading FGID in the infant/toddler (41/57) and the children group (66/124). Retentive encopresis was present in about 1/5 of children (29/132 or 21.9%) Accompanied encopresis was mainly observed in the age group of 4–10 years (22/66 or 33.3%, χ²=9.9431, p Discussion Frequency of functional constipation in paediatric patients in tertiary hospital setting, as well as sex and age distribution, is comparable to reported incidences in the population. The discordance of referral and final diagnosis shows that constipation is not adequately recognized in primary care, but when recognized, it is mostly diagnosed correctly. Conclusion Functional constipation is not recognized enough in primary care and more efforts are needed to assure a positive diagnosis of this disorder prior to the referral to tertiary care.

Aim This study aimed to explore referral and triage pathways for paediatric patients referred to an Australian hospital with bowel dysfunction (isolated or mixed bowel and bladder). Methods We conducted a retrospective audit of patients who attended their first clinic appointment during April to June 2014. Patients were included if they: (i) were a new patient referred for symptoms of constipation, soiling, daytime urinary incontinence or enuresis; and (ii) attended the encopresis, general medicine, continence, gastroenterology, paediatric surgery, urology, renal or Child and Adolescent Mental Health clinic. Patients with an organic cause (e.g. Hirschsprung disease) for their dysfunction were excluded. Results Of 1485 new patients seen at our targeted clinics, 281 (18.9%) had symptoms of bowel and/or bladder dysfunction. After excluding patients aged younger than 3 years (n = 43) and those with isolated bladder dysfunction (n = 130), 56 were referred for isolated bowel dysfunction and 52 for mixed bowel and bladder dysfunction. The median wait time from referral to first appointment was 3.8 months. Median wait times varied across symptom groups (isolated bowel, 4.6 months; mixed 3.4 months) and clinics (encopresis, 7.7 months; general medicine, 2.5 months). Over a 12-month period, patients attended an average of 3.5 appointments (isolated bowel, mean 3 appointments; mixed, mean 4 appointments). Conclusion Paediatric patients with symptoms of bowel and bladder dysfunction wait several months to be seen in a public tertiary referral hospital. Alternative pathways for care, such as community-based primary care, need to be explored to improve timely management.

Elimination disorders are common childhood concerns that are often distressing for children and parents. These disorders occur at a higher rate in children with neurodevelopmental disorders including autism spectrum disorder (ASD) and can lead to significant functional impairment at home, school, and in the community. Enuresis, or developmentally inappropriate urination behaviors, can occur during the day, at night, or both. Encopresis, or fecal incontinence, is the passage of stool into inappropriate places such as one’s clothing or onto the floor. Biological and psychobehavioral underpinnings of elimination disorders will be addressed in this chapter. Gold standard interdisciplinary treatment of elimination disorders will be discussed and the evidence for this approach reviewed.

Encopresis or fecal incontinence is a common childhood concern in which a child over the developmental age of 4 years passes stool into an inappropriate place (e.g., underwear or onto the floor). Although this condition can be diagnosed in adulthood, it is often first diagnosed in childhood or early adolescence. Encopresis has both biologic and behavioral components, is often very distressing for the youth and their family, and can cause significant disruption in day-to-day functioning. This chapter addresses biological and behavioral factors and reviews the evidence-based cognitive behavioral interventions for encopresis. The most common biological contributor to fecal soiling is constipation, which should be medically managed at the outset and throughout the course of treatment for this condition. Behavioral contributors such as stool withholding, delayed defecation, and noncompliance with toileting routines may also need to be addressed in order to achieve full symptom remission. Cognitive factors such as incorrect assumptions about the reasons for soiling, learned helplessness, and fear of the toilet or stooling should also be assessed and intervened upon if present. A combined medical and behavioral/psychological treatment approach is recommended.

Managing colorectal surgery conditions in infants and children presents a highly detailed and technical challenge that, in many cases, requires formal training, experience, and expertise. In addition to the wide array of congenital anomalies that surgeons may encounter, this chapter will cover conditions that are also experienced in adults; however, the evaluation and management of these disease states needs to be tailored to the pediatric population.

CASE Sonia is a 7-year-old old girl who was referred to the Developmental-Behavioral Pediatrics Clinic by the Pediatric Urology Clinic because of persistent wetting and soiling behaviors. Since age 3 years, she has had a history of encopresis (and wetting) for which she has seen gastroenterology and urology specialists. The mother reports that Sonia has accidents almost daily, and she is not upset when sitting in her urine or feces. She dislikes going into the bathroom or sitting on the toilet by herself. She participated in a behavior modification program associated with the pediatric urology clinic, which helps children learn healthy voiding habits and achieve continence.Sonia also has anxious behaviors. She bites her nails and chews on her hair or shirt. She is afraid of small spaces such as those between the bed and the wall and needs to have stuffed animals cover them. Other instances that trigger her anxious behaviors include loud noises, having a substitute teacher, being separated from her mother, and going to certain bathrooms or new places. She also has severe tantrums, which involve throwing and breaking objects, kicking, and hitting her head against doors.A cognitive behavioral therapy program was recommended to target anxiety symptoms, in addition to timed toileting after meals and polyethylene glycol. At a clinic visit several months later, symptoms of anxiety, encopresis, and enuresis persisted. Cognitive behavior therapy was continued and sertraline 25 mg was prescribed for anxiety. In addition, she was referred to a pediatrician who specializes in relaxation techniques and hypnotherapy.Sonia showed modest improvement with these interventions. There were fewer episodes of angry outbursts and a decrease in soiling and wetting, but at times, but she continued to have intermittent periods of wetting and soiling and fear of going to the bathroom by herself persisted.(This Challenging Case extends observations reviewed in a previous Challenging Case: J Dev Behav Pediatr 2010;531:513-515; DOI: 10.1097/DBP.0b013e3181e5a464.).

Severe constipation and encopresis are significant problems in the pediatric population. Medical management succeeds in 50–70%; however, surgical considerations are necessary for the remainder such as the antegrade continence enema (ACE). The purpose of this study is to assess the long-term outcomes following the ACE procedure. All patients undergoing an ACE over a 14-year period were included. Data on clinical conditions, treatments, and outcomes were collected. A successful outcome was defined as remaining clean with ≤ 1 accident per week. Comparative data were analyzed using the Fisher’s exact test, Mann–Whitney U test, or Student’s t test. There were 42 ACE patients, and overall, 79% had improvement in their bowel regimens. Encopresis rates decreased from 79 to 5% (P