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Journal of Family Medicine & Community Health Management of Children's

Constipation: Effect of Adjunct Physical Activity and Behavior Modifications

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 Central Journal of Family Medicine & Community Health
Research Article *Corresponding author
Marwa Khalil, Public Health Department, Faculty of

Management of Children’s Medicine, Zagazig University, Egypt, Tel: 1-4168065346;

Email:

Constipation: Effect of Adjunct

Submitted: 29 May 2015
Accepted: 18 June 2015
Published: 20 June 2015

Physical Activity and Behavior Copyright

© 2015 Khalil

Modifications OPEN ACCESS

Keywords
Marwa Khalil* • Functional constipation
Public Health Department, Zagazig University, Egypt • Management
• Health education
• Physical activity
Abstract • Life style modifications

Background and objectives: Chronic constipation is one of the most common, yet
challenging conditions encountered in pediatric practice. Despite the best treatments,
however, multiple cohort studies have demonstrated that recurrence can be as high as
50%. The aim of this study is to explore the effect of health education about physical
activity and behavior modifications on decreasing the recurrence rate in children
managed from functional constipation.
Methods: This study was conducted in two tertiary pediatric surgery centers
in UAE. Children (4-13 years) who visited these centers suffering from functional
constipation were included. Patients were randomly assigned to either group (1) who
were managed through the use of medical treatment and dietary modification or group
(2) who received the same previous treatment in addition to parent’s education about
bowel training and life style modification. Both groups were followed up for two years.
Results: Health education significantly decreased the time needed for treating
constipation (t= 11.1, 95% CI= 2.47-3.53). It had also significantly increased the
duration of normal bowel habits (t = 10.9, 95% CI= 2.72-1.88) and decreases the
number of recurrent attacks (RR = 4, 95% CI= 1.15-17.56).
Conclusion: Adjunct health education about the physical activity and behavioral
modifications was associated with statistically significant less time for management and
less recurrence attacks during the management of functional constipation in children.

INTRODUCTION to develop, leading to fecal incontinence or encopresis [3,4].

Chronic constipation is one of the most common, yet
challenging conditions encountered in pediatric practice [1].
The available data indicate that constipation is on the rise. A
recent analysis of longitudinal data in the USA beginning from
1979 showed nearly 4-fold increase in rates of constipation
during the last decade. There was a surge in both outpatient
clinic visits and hospitalizations due to constipation between
1992 and 2004, with more than a doubling of rates in diagnosing
constipation from outpatient clinics and nearly 4-fold increase in
rates of hospital discharge under the diagnosis of constipation.
Furthermore, children under 15 years had the highest number
of clinic visits for constipation [2]. In addition, 5.4 million
prescriptions were filled for constipation in the USA in 2004. All
these facts prove that constipation is a growing health problem
among children worldwide. Beyond the neonatal period, the most
common cause of constipation is functional. If left untreated over
time, painful defecation in children can cause fearful reactions
Functional constipation is defined as the passage of less than
two large-diameter stools per week with or without the presence
of retentive posturing or behaviors in the absence of genetic,
structural, endocrine or metabolic disorders [5].
The pediatric Rome III criteria were released in 2006, which
recognized Functional constipation as a separate clinical entity
by combining features of functional fecal retention and functional
constipation. Furthermore, duration of symptoms was reduced
to 8 weeks [6].
Several risk factors have been identified in association with
pediatric constipation. Low consumption of dietary fiber has long
been considered as one of the leading risk factors. Undigested
fibers in the colon are thought to increase the colonic transit and
increase stool output. Two studies among older children also
noted that children with constipation consume significantly less
amount of dietary fiber than controls [7,8].

Cite this article: Khalil M (2015) Management of Children’s Constipation: Effect of Adjunct Physical Activity and Behavior Modifications. J Family Med Com-
munity Health 2(4): 1041.

Central
Other demonstrated risk factors are extreme low birth
weight [9], positive family history [7,10] , high consumption of
junk foods and sedentary life style [10,11].
The medical management of chronic constipation in children
has three phases: complete evacuation if impaction is present,
sustained evacuation of impaction, and weaning from intervention
through adjustment of medications if necessary [12,13]. From a
dietary perspective, constipating foods should be reduced or
eliminated completely from the child’s diet [12]. The causal role
of exercise in managing constipation was not confirmed. Several
studies showed that walking was positively associated with
bowel movement [14,15]. Behavioral modification and education
of the patient and family was found to be an integral part of
maintenance therapy of constipation in children [16].
Despite the best treatments, however, multiple cohort studies
have demonstrated that recurrence can be as high as 50% [17].
The aim of the current study is to explore the effect of physical
activity and behavior modifications on decreasing the recurrence
rate of constipation in children managed from functional
constipation.
Patients and methods
This study was conducted in two tertiary pediatric surgery
centers in UAE during the period from February 2008 to February
2015. The inclusion criteria were all children aged 4-13 years
who visited these centers suffering from functional constipation.
The exclusion criteria were the neurologically impaired patients
and those who had anorectal or colon surgery. The last date of
recruitment was February 2013.
The aim of the study was explained to the parents in the first
outpatient clinic visit and consent was obtained from the parents
to be enrolled in the study.
Patients were stratified according to their age group, gender
and socio-demographic criteria and then randomly assigned to one
of the intervention groups. Patients in group (1) were managed
according to the guidelines of constipation management in the
two centers through the use of medical treatment and dietary
modification. Patients in group (2) received their treatment
with same guidelines of medical and dietary modifications in
addition to parent’s education about bowel training and life style
modification.
Medical protocol
The medical management protocol is starting by fecal
disimpaction by using either inpatient Glycin enema or Oral
Polyethylene Glycol fecal disimpaction dose. The choice was
based on the treating doctor’s evaluation for the degree of
severity of constipation as well as parent’s preference.
Patients were followed up after one week with plain
abdominal x ray, in cases of failed fecal disimpaction by Oral
Polyethylene Glycol; the patient was admitted and managed with
Glycin enema.
Criteria for successful management of fecal disimpaction
were complete emptiness of the whole colon and rectum from
stool as evident by plain abdominal x ray.
J Family Med Community Health 2(4): 1041 (2015)
Khalil (2015)
Email:
Polyethylene Glycol was used as a maintenance therapy
for the treatment of constipation. Senna based medications, in
adjunct with Polyethylene Glycol, was used in some cases during
maintenance therapy for a maximum of 3 months continuously
and/or with a gap of 3 months if required to be repeated.
Dietary protocol
The dietary modifications were given by the dietitian. Parents
were educated to give their children a balanced diet that includes
whole grains, fruits and vegetables. The recommended amount of
fiber was calculated according to Mason et al., 2004 [18] with the
use of the formula [age in years + 5 = number of grams of fiber/
day]
Parents were also educated to decrease foods high in fat and
sugar (including sodas, cookies and candies), french fries and fast
foods.
Health education protocol
The main aim of the health education was to improve the
knowledge of parents and change their attitude and practice.
A health education session on a person to person basis was
arranged. The following information was given to the parents:
- Duration and timing of toilet training (sitting for 5-10
minutes on the toilet 20 minutes after meals)
- Using a proper toilet base for younger children as well as
foot-stool for supporting the legs.
- Increasing the level of physical activity of the child
by letting him/her practice any sport (e.g. swimming,
running, cycling, jump rope…) at least 5 hours per week
and at the same time limiting the use of electronic games
and watching television to 1-2 hours per day.
- Keeping track of children’s successes on a calendar
or behavior tracking record, and to set rewards for
successes. Parents were also instructed to teach children
internal control and praise self-regulation of their bowel
patterns.
Enforcement of the message given to the parents in the
medical and dietary protocols that had been given by the treating
physicians and the dietitian respectively was also done. Written
instructions were given to the parents to reinforce the previously
given messages.
Follow up protocol
Follow up of both groups was done on monthly basis for
the first 3 months then every 3 months for one year then every
6 months for two years. Plain abdominal X- ray was done in
every clinic visit in the first one year of follow up post fecal
disimpaction. Compliance with the plan of treatment in both
groups was followed up and review of the management plan was
done in each follow up visit. Data were collected and statistically
analyzed by using SPSS 17.
Outcome assessment
The assessors of the outcome were blind to the groups of the
patients. The primary outcomes were successful recovery and
no recurrence of constipation. A successful recovery has been
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defined as independent toileting of normal stool volumes without
the need for medications.
Recurrence of constipation has been defined as recurrence
of the same symptoms before treatment and /or loaded right,
transverse and left colon with stool as proved by abdominal X
-ray.
As secondary outcomes the duration required to treat
constipation, the duration of normal bowel motions before
recurrence and the need of using senna based medications were
also assessed.
Data Analysis
The following data were analyzed, patients demographics,
family history of constipation, the length of constipation, the
duration required to treat constipation (no medication required
any more), the need for senna based medication, recurrence
of constipation, the duration of normal bowel habit before
recurrence of constipation, frequency of recurrent constipation
and the follow up period.
RESULTS
During the study period 187 patients visited the outpatient
clinic for functional constipation, 152 patients agreed to
participate in the study (response rate 81.3%). After 2 years of
follow up the remaining patients were 141 with 73 of them in
group (1) and 68 patients in group (2) Figure 1.
The age of the patients ranged from 4-13 years. There were
a total of 80 girls and 61 boys. The demographic criteria and the
family history of constipation in both groups are shown in Table
1.
The mean duration of constipation was 13 ± 3 months in
group (1) and 15 ± 9 months in group (2) (t = 1.8, P > 0.05). Table

Children with functional

constipation (n=190)

Patients excluded
(n =13)

Patients eligible for

recruitment (n = 187)

Parents refused to
participate (n =35)

Remaining patients
(n=152)
Stratification of patients
(n=152)

Group 1 Group 2
(n=76) (n=76)

Follow up for 2 years

Drop-outs (n=3) Drop-outs (n=8)

Remaining Patients Remaining Patients

(n=73) (n=68)

Figure 1 Study flow chart.

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Table 1: Demographic criteria of patients in both groups.

Group (1) Group (2)
Variable Significance
N = 73 N = 68
t = 1.8
Age (X` ± SD) 5.8 ± 3.1 years 7 ± 4.6 years
P > 0.05
Boys 30 31 X2 = 0.29
Gender
Girls 43 37 P > 0.05
X2 = 2.1
Positive family history 13 patients 19 patients
P > 0.05

Table 2: Outcome assessment of both groups.

Group (1) Group (2)
Variable Significance
N = 73 N = 68
t = 11.1
Mean duration to treat constipation 8 ± 2 months 5 ± 1 months
95% CI= 2.47-3.53
26 patients 14 patients RR = 1.7
Need of Senna based medications
(35.6%) (20.6%) 95% CI= 0.96 -3.24
28 patients 16 patients RR = 1.6
Recurrent constipation
(38.4%) (23.5%) 95% CI= 0.94 - 2.9
Duration of normal bowel motions t = 10.9
3.8 ± 1.1 months 6.1 ± 1.4 months
before recurrence 95% CI= 2.72-1.88
Patients with more than one 13 patients 3 patients RR = 4
recurrence of constipation (17.8%) (4.4%) 95% CI= 1.15-17.56

2 shows the difference between the two groups in their outcome
assessment. Group (2) needed significantly less time in treating
their constipation, had significantly more time of normal bowel
habits and were significantly associated with less number of
recurrence attacks. There were fewer patients who needed the
use of stimulant senna medications and fewer patients with
recurrence in group (2) but this difference was not statistically
significant.
DISCUSSION
This study aims at testing the effect of physical activity and
life style modification in preventing the recurrence of functional
constipation in children. All children aged 4-13 years who
visited two tertiary care centers in UAE suffering from functional
constipation were included in the study. The female represented
56.7% of the study population. Gender specific prevalence of
constipation varies between studies. Some studies have reported
no difference in prevalence of constipation between girls and
boys [19-22], while others found significantly higher prevalence
in girls [23].
Positive family history of constipation was found in 22.6% of
the patients in our study. Other studies concluded that positive
family history is one of the risk factors of constipation [7,10].
Management of constipation encompasses several facets.
However, only few randomized controlled trials are available
to assess therapeutic options currently being used in treatment
[24].
The guidelines for management of functional constipation
in the two tertiary care centers include the use of medications
and dietary modifications. Disimpaction is the first step in
the medical protocol that is necessary before initiation of
maintenance therapy. It may be accomplished with either oral or
rectal medication. In uncontrolled clinical trials, disimpaction by
the oral route, the rectal route, or a combination of both has been
shown to be effective [25].
Once the impaction has been removed, the treatment focuses
on the prevention of recurrence. The maintenance therapy
consists of dietary interventions and laxatives to assure that
bowel movements occur at normal intervals with good evacuation.
Dietary modifications include increased intake of fibers, fluids
and carbohydrate. Studies had shown that carbohydrates and
especially sorbitol, found in some juices such as prune, pear, and
apple juices, can cause increased frequency and water content of
stools [26,27].
Dietary education, especially supplementation of fiber has
become first line treatment of chronic functional constipation in
children; however, the evidence is weak that diet plays a major
role in childhood constipation. Loening-Baucke et al., [28] found
glucomannan (a fiber gel polysaccharide from the tubers of
the Japanese Konjac plant) to be beneficial in the treatment of
constipation with and without encopresis in children in a double-
blind, randomized, crossover study.
Another study conducted by Jennings et al, revealed that fluid
and fiber intake was higher in children without constipation,
therefore supporting the association of symptoms of constipation
to low fiber intake [29].
In our study 61.6% of the patients in the group who received
only medication and dietary modifications had no recurrence of
constipation, which is indicating a good response to this type of
management.
Relapse is common in managing childhood functional
constipation, therefore adequate maintenance therapy is strongly
recommended. Behavioral modification had been revealed to be
an integral part of the maintenance therapy [16].
A randomized control trial which compared conventional
treatment alone and conventional treatment with added

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behavioural therapy failed to demonstrate significant difference
in improvement of defecation frequency and fecal soiling [30]. In
contrast to this, a web based behavioural therapy plus laxatives
with conventional treatment showed reduced fecal soiling,
increased defecation in the toilet, and increased unprompted
trips to the toilet in study group [31].
Another study recommends that Behavioural management
should be used in conjunction with medication therapy [32].
Studies focusing on exercise and constipation in children
and adolescents were few and results were inconsistent. Two
studies on children have reported a negative association between
physical activity and constipation [33,34], while another study on
adolescents found no association between moderate-to-vigorous
exercise and constipation [35].
However, daily moderate exercise was associated with a
44% reduction in risk of constipation in women [36]. Regular
exercise has been recommended in elderly constipated patients
[37-39], although the causal role of diminished exercise leading
to constipation has not been confirmed [40].
In our study we found that adjunct health education about the
inclusion of physical activity, toilet training and follow up with
a behaviour training report was effective in decreasing the time
needed to treat constipation, increasing the duration of normal
bowel habits and less number of recurrence attacks. However,
this adjunct therapy was not significantly effective in decreasing
the use of stimulant senna medications or significantly decreasing
the occurrence of recurrence.
CONCLUSION
In the current study, Introduction of physical activity and
behavioral modifications for the management of functional
constipation in children was associated with statistically
significant less time required for constipation management and
less recurrence of constipation. Although it was not statistically
significant, there was less need for extra medication for
management of functional constipation when physical activity
and behavioral modification were adjunct to medical and dietary
protocols in the management.
ACKNOWLEDGMENT
Special thanks for the pediatric surgery team and the
dieticians in the two tertiary pediatric surgery centers where
this study took place for revising the medical and dietary
protocols included in the manuscript and for their cooperation in
conducting this study.
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Cite this article

Khalil M (2015) Management of Children’s Constipation: Effect of Adjunct Physical Activity and Behavior Modifications. J Family Med Community Health 2(4): 1041.

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