Obstipatie bij kinderen

Mugie SM, et al. Best Pract Clin Gastroenterol 2011 Prevalentie kinderen 0.7% tot 30% 0-10% >10-20% >20-30% >30-40% Mugie SM, et al. Best Pract Clin Gastroenterol 2011

Obstipatie is belasting voor gezondheidszorg US 1,7 miljoen kinderen Bezoeken vaker SEH Verzuimen vaker van school Kosten: $3,374/jr versus $1,096/jr Liem O, et al. J Pediatr 2009

Wat is normaal? Eerste levensweek: 4 defs per dag (dit kan veel minder zijn bij borstvoeding) Tweede week tot 3 maanden: 3 defs per dag bij borstvoeding; 2 defs per dag bij flesvoeding 2 jaar: Iets minder dan 2 defs per dag > 4 jaar: Iets meer dan 1 def per dag

Hoe beoordeel je of er obstipatie is? De diagnose functionele obstipatie is gebaseerd op anamnese en lichamelijk onderzoek Tabbers MM et al ESPHGAN/NASPHGAN JPGN 2014;58: 258–274 Bardisa-Ezcurra L et al NICE. BMJ. 2010 Jun 1;340:c2585

Rome III criteria voor functionele obstipatie Onderzoek in 336 kinderen met functionele obstipatie waarin Rome III criteria zijn getoetst : 39% ontlasting frequentie < 2/week 75% fecale incontinentie 60% pijn tijdens ontlasting 49% olifanten drollen 75% retentive posturing 49% fecale massa bij rectaal toucher Devanarayana N, et al, J Trop Pediatr. 2011 Burgers R, et al, J Pediatr. 2012

Anamnese

Tenminste 2 criteria bij anamnese en LO 2 defecaties per week Voorafgaand ophoudgedrag of opzettelijk ophouden ontlasting Pijnlijke en/of harde ontlasting Na bereiken zindelijkheid Tenminste 1 keer per week fecale incontinentie Olifantendrol die toilet blokkeert Tabbers MM et al ESPHGAN/NASPHGAN JPGN 2014;58: 258–274

Leeftijd <4 jaar Bijkomende symptomen: prikkelbaarheid, verminderde eetlust, en/of snel verzadigd zijn, die onmiddellijk verdwijnen na ontlasting Tabbers MM et al ESPHGAN/NASPHGAN JPGN 2014;58: 258–274

Lichamelijk onderzoek Buik Wervelkolom Perianale regio Groei Neurologisch

Bevinding LO Aanwezigheid grote palpabele massa in buik (scybala) past bij obstipatie Tabbers MM et al ESPHGAN/NASPHGAN JPGN 2014;58: 258–274

Rectaal toucher bij< 2 criteria Fecale massa past bij obstipatie Lege ampul voegt niks toe

Buikpijn en obstipatie Kinderen met functionele obstipatie hebben vaak buikpijn Kinderen met functionele buikpijn hebben meestal geen obstipatie Bij oudere kinderen met buikpijn en obstipatie moet aan het prikkelbare darm syndroom worden gedacht

Aanvullende diagnostiek

Aanvullende diagnostiek

Wat discrimineert tussen functionele obstipatie en obstipatie tgv onderliggende aandoening?

Alarm symptomen

Bij Verwijzen

Wat zijn oorzaken van obstipatie? En wat betekent dat voor je beleid?

Quality of evidence: very low Fibers Quality of evidence: very low Evidence does not support the use of fiber supplements in the treatment of childhood constipation Based on expert opinion, we recommend a normal fiber intake in children with constipation Voting: 6,8,9,9,9,9,9,9 Tabbers MM et al ESPHGAN/NASPHGAN JPGN 2014;58: 258–274 22

Quality of evidence, low Fluid Quality of evidence, low Evidence does not support the use of extra fluid intake in childhood constipation Based on expert opinion, we recommend a normal fluid intake in children with constipation Voting: 9,9,9,9,9,9,9,9 The absorptive capacity of the small bowel approximates 15 liters per day in the adult (Binder & Mehta, 1989). Even if excess liquid did pass from the ileocecal valve into the large intestine, the colon is capable of absorbing up to 5 liters per day. These study data strongly suggest that increasing the water or high osmolarity liquid intake in children with constipation of a moderate to severe degree has no effect on alleviating stooling difficulties. Alteration of stool consistency requires the addition of nonabsorbable osmotic substances to the diet or otherwise modifying colonic function or motility. Advising parents of constipated children to increase liquid intake is not helpful and should not be recommended unless history suggests that the child's liquid intake is inadequate for a normal child of that age and activity level. Tabbers MM et al ESPHGAN/NASPHGAN JPGN 2014;58: 258–274 23

Quality of evidence: no evidence Physical activity Quality of evidence: no evidence There are no randomized studies to recommend increased physical activity in childhood constipation Based on expert opinion, we recommend a normal physical activity in children with constipation Voting: 9,9,9,9,9,9,9,9 The absorptive capacity of the small bowel approximates 15 liters per day in the adult (Binder & Mehta, 1989). Even if excess liquid did pass from the ileocecal valve into the large intestine, the colon is capable of absorbing up to 5 liters per day. These study data strongly suggest that increasing the water or high osmolarity liquid intake in children with constipation of a moderate to severe degree has no effect on alleviating stooling difficulties. Alteration of stool consistency requires the addition of nonabsorbable osmotic substances to the diet or otherwise modifying colonic function or motility. Advising parents of constipated children to increase liquid intake is not helpful and should not be recommended unless history suggests that the child's liquid intake is inadequate for a normal child of that age and activity level. Tabbers MM et al ESPHGAN/NASPHGAN JPGN 2014;58: 258–274 24

Vicieuze cirkel aangeleerd gedrag pijn ophoudgedrag harde en/of grote stoelgang 25

Quality of evidence: low Behavioral therapy Quality of evidence: low Evidence does not support the use of intensive behavioral protocolized therapy program in addition to conventional treatment in childhood constipation Voting: 9,9,9,9,9,9,9,9 Based on expert opinion, we recommend demystification, explanation and toilet training (in children with a developmental age of at least 4 years) in the treatment of childhood constipation Voting: 7,8,8,8,8,9,9,9 The absorptive capacity of the small bowel approximates 15 liters per day in the adult (Binder & Mehta, 1989). Even if excess liquid did pass from the ileocecal valve into the large intestine, the colon is capable of absorbing up to 5 liters per day. These study data strongly suggest that increasing the water or high osmolarity liquid intake in children with constipation of a moderate to severe degree has no effect on alleviating stooling difficulties. Alteration of stool consistency requires the addition of nonabsorbable osmotic substances to the diet or otherwise modifying colonic function or motility. Advising parents of constipated children to increase liquid intake is not helpful and should not be recommended unless history suggests that the child's liquid intake is inadequate for a normal child of that age and activity level. 26

Prognose Functionele obstipatie kan een chronisch recidiverende aandoening worden 50 tot 60% is na adequate behandeling na 1 jaar klachtenvrij en gebruikt geen laxans meer Uitstel van adequate behandeling is gerelateerd aan een slechtere prognose Tabbers MM et al ESPHGAN/NASPHGAN JPGN 2014;58: 258–274

Wat is een goede behandeling van functionele obstipatie?

2011

Stool Frequency per Week Cochrane Database Syst Rev 2011

Which laxative should be given for maintenance therapy? Quality of evidence: very low The use of PEG with or without electrolytes is recommended as the first-line maintenance treatment. A starting dose of 0.4 g / kg/ day is recommended and the dose should be adjusted according to the clinical response. Voting: 7, 7, 8, 8, 9, 9. The absorptive capacity of the small bowel approximates 15 liters per day in the adult (Binder & Mehta, 1989). Even if excess liquid did pass from the ileocecal valve into the large intestine, the colon is capable of absorbing up to 5 liters per day. These study data strongly suggest that increasing the water or high osmolarity liquid intake in children with constipation of a moderate to severe degree has no effect on alleviating stooling difficulties. Alteration of stool consistency requires the addition of nonabsorbable osmotic substances to the diet or otherwise modifying colonic function or motility. Advising parents of constipated children to increase liquid intake is not helpful and should not be recommended unless history suggests that the child's liquid intake is inadequate for a normal child of that age and activity level. 31

Maintenance therapy Based on expert opinion, maintenance treatment should continue for at least 2 months. All symptoms of constipation symptoms should be resolved for at least 1 month before discontinuation of treatment. Treatment should be decreased gradually. Voting: 7,7,8,8,8,8,9,9 Based on expert opinion, in the developmental stage of toilet training, medication should only be stopped once toilet training is achieved. Voting: 7,7,7,8,8,9,9,9

Conclusies De aanwezigheid van obstipatie wordt gebaseerd op anamnese en lichamelijk onderzoek De definitie van obstipatie is gebaseerd op de ROME III criteria De diagnose functionele obstipatie wordt gesteld na het uitsluiten van alarmsymptomen

Conclusies Behandeling start met demystificatie, uitleg en toilet training (bij kinderen met een ontwikkelingsleeftijd van 4 jaar) Kinderen met obstipatie hebben baat bij het advies over een normaal gezond dieet, normale vochtinname en lichaamsbeweging PEG is eerste keus laxans wanneer na 2 weken klachten persisteren Enemas hebben geen rol bij onderhoudsbehandeling

Wat is het effect van kinderfysiotherapie op persisteren van klachten na 12 maanden?