Eur J Pediatr. 2012 Feb 24. [Epub ahead of print]
Practical consensus guidelines for the management of enuresis.
Vande Walle J, Rittig S, Bauer S, Eggert P, Marschall-Kehrel D, Tekgul S.
Source
Pediatric Nephrology Unit, Ghent University Hospital, Ghent, Belgium,
johan.vandewalle@uzgent.be.
Abstract
Despite the high prevalence of enuresis, the professional training of doctors in the
evaluation and management of this condition is often minimal and/or inconsistent.
Therefore, patient care is neither optimal nor efficient, which can have a profound impact
on affected children and their families. Once comprehensive history taking and
evaluation has eliminated daytime symptoms or comorbidities, monosymptomatic
enuresis can be managed efficaciously in the majority of patients. Nonmonosymptomatic enuresis is often a more complex condition; these patients may
benefit from referral to specialty care centers. We outline two alternative strategies to
determine the most appropriate course of care. The first is a basic assessment covering
only the essential components of diagnostic investigation which can be carried out in
one office visit. The second strategy includes several additional evaluations including
completion of a voiding diary, which requires extra time during the initial consultation and
two office visits before treatment or specialty referral is provided. This should yield
greater success than first-line treatment. Conclusion: This guideline, endorsed by major
international pediatric urology and nephrology societies, aims to equip a general
pediatric practice in both primary and secondary care with simple yet comprehensive
guidelines and practical tools (i.e., checklists, diary templates, and quick-reference
flowcharts) for complete evaluation and successful treatment of enuresis.
1
Acta Paediatr. 2012 Feb 23. doi: 10.1111/j.1651-2227.2012.02624.x. [Epub ahead of
print]
Differentiation of subgroups of monosymptomatic enuresis according to prepulse
inhibition of the startle reflex.
Eggert P, Freischmidt S, Bismarck PV, Schulz-Jürgensen S.
Source
Department of Pediatrics, University Clinics of Schleswig-Holstein, Kiel, Germany.
Abstract
Monosymptomatic Aim: enuresis (ME) is a common disorder in children with serious
social and psychological consequences. Treatment is usually initiated with desaminoarginine vasopressin (dDAVP) and/or alarm therapy as first-line treatment and
imipramine as second-line. All treatments have proven efficacy, but are not successful
with all patients. Therefore, a differentiation into A group subgroups according to
treatment efficacy would be beneficial. Methods: of patients resistant to first-line
treatment was treated with imipramine and compared with matched controls successfully
treated with dDAVP and/or alarm therapy. Prepulse inhibition (PPI) to acoustic startle
reflexes was measured in In a group of 23 nonresponders, the median PPI was 72% all
patients. Results: (range 43-94%) compared with the matched dDAVP/alarm responders with a median PPI of 26% (range 0-61%) (p<0.0001). The response rate
to imipramine was
The presented data provide evidence that PPI allows to 87%.
Conclusion: identify two subgroups of ME. The results offer further insight into (at least)
two different pathomechanisms involved in ME: (i) a maturational delay of reflex
inhibition with reduced PPI and (ii) a normal PPI, possibly with abnormal sleep patterns,
that can be influenced by imipramine.
2
BJU Int. 2012 Feb 7. doi: 10.1111/j.1464-410X.2011.10918.x. [Epub ahead of print]
Desmopressin and oxybutynin in monosymptomatic nocturnal enuresis: a
randomized, double-blind, placebo-controlled trial and an assessment of
predictive factors.
Montaldo P, Tafuro L, Rea M, Narciso V, Iossa AC, Gado RD.
Source
Department of Pediatrics, Second University of Naples, Naples, Italy.
Abstract
4 What's known on the Study Type - Therapy (case series) Level of Evidence subject?
and What does the study add? The desmopressin analogue to antidiuretic vasopressin
is an evidence-based therapy but conflicting results are provided regarding the initial
dose of oral desmopressin. Previous studies report the use of a combined therapy with
desmopressin and oxybutynin to treat desmopressin-resistant monosymptomatic
nocturnal enuresis. These studies show promising results, but they suffer from lack of
randomization and lack of a placebo-controlled patient group and are of small sample
size. In addition to this, no predictive factors of response to the combined therapy have
been considered. This study showed no µg desmopressin initial µg or a 240
significant difference between either a 120 dose with regard to degree of response. The
study is the first randomized, double-blinded, placebo-controlled trial showing the
efficacy of combination therapy with desmopressin plus oxybutynin for
monosymptomatic nocturnal enuresis. Furthermore, bladder volume and wall thickness
index, nocturnal polyuria and voiding latency were assessed as predictive factors of
response to the therapy.
OBJECTIVES:
To assess the efficacy of desmopressin plus oxybutynin and compare two • µg) in a
randomized, starting dosages of desmopressin (120 and 240 double-blinded, placebocontrolled trial for children with monosymptomatic nocturnal enuresis The (MNE)
resistant to desmopressin. • predictive factors of children with MNE responsive to
desmopressin and combination therapy were also evaluated.
PATIENTS AND METHODS:
Our sample included 206 patients aged between 6 and 13 (mean age 10.6 ± • The
patients 2.9 years), 117 males. All patients were required to have MNE. • were randomly
divided into two groups: the first group was given oral melt All patients who had µg, for
2 weeks. • µg and the second group 240 120 experienced failure of treatment with
sublingually administered desmopressin mg oxybutynin or desmopressin plus alone
were given either desmopressin plus 5 As predictive placebo in a randomized, doubleblinded trial for 4 weeks. • factors, bladder volume and wall thickness index, nocturnal
polyuria and voiding latency were considered.
3
RESULTS:
µg patients µg and 240 There was no significant difference between the 120 • The
oxybutynin group showed a higher rate of full and in terms of response. • partial
responses (45% success) compared with the placebo group (17% success), P < The
responders to combined oxybutynin and desmopressin had 0.01. • significantly lower
bladder volume and wall thickness index than the other patients.
CONCLUSIONS:
Our findings highlight that anticholinergic agents may play an important • role for a
subset of children with enuresis who have a restricted bladder capacity and
Ultrasonography-measured bladder variables can thickened bladder wall. • Predictive
factors can help to provide useful predictive clues for MNE. • differentiate treatment
subtypes and guide clinical management in primary nocturnal enuresis.
4
J Pediatr Urol. 2012 Feb;8(1):29-34. Epub 2011 Feb 4.
Predictors of severity and treatment response in children with monosymptomatic
nocturnal enuresis receiving behavioral therapy.
Elsayed ER, Abdalla MM, Eladl M, Gabr A, Siam AG, Abdelrahman HM.
Source
Urology Department, Zagazig University Hospitals, Egypt.
Abstract
OBJECTIVE:
To evaluate the role of bladder volume and bladder wall thickness measurement by
ultrasound in assessing severity and predicting response to behavioral therapy in
children with monosymptomatic nocturnal enuresis.
METHODS:
122 children (68 boys and 54 girls) aged 5-9 years underwent ultrasound evaluation of
bladder volume and bladder wall thickness, followed by calculation of the bladder
volume wall thickness index (BVWI). They were treated using first-line management
(behavioral therapy) for 4 months. Correlation of severity and treatment response to
ultrasound bladder measurements was investigated.
RESULTS:
Only 74 children completed the study: 16 showed complete response to treatment, 25
good response, 18 partial response, and 15 children showed no response. Age, gender
and location of residence did not correlate to severity or to treatment response.
Ultrasound measured bladder volume also did not correlate to either severity or
response. Bladder wall thickness showed a strong correlation to both severity and
response to treatment, as did BVWI.
CONCLUSION:
Ultrasound measured bladder wall thickness and BVWI are strongly associated with the
severity of nocturnal enuresis and are highly predictive of treatment response to
behavioral therapy. It is recommended that any child with monosymptomatic nocturnal
enuresis should undergo an abdominal ultrasound examination before starting
treatment.
5
J Urol. 2012 Feb;187(2):664-9. Epub 2011 Dec 16.
Tailoring treatment of monosymptomatic nocturnal enuresis: the role of maximum
voided capacity.
Tauris LH, Kamperis K, Hagstroem S, Bower WF, Rittig S.
Source
Department of Pediatrics, Aarhus University Hospital, Skejby, Denmark.
lhjelle@dadlnet.dk
Abstract
PURPOSE:
We evaluated bladder reservoir function in children with monosymptomatic nocturnal
enuresis with and without response to desmopressin, and assessed the importance of
first morning voiding when defining maximum voided volume.
MATERIALS AND METHODS:
A total of 238 patients 5 to 15 years old with monosymptomatic nocturnal enuresis
completed 2 weeks of enuresis recordings and 4 days of frequency-volume charts. Of
the patients 186 completed subsequent home recordings during titration with
desmopressin. Maximum voided volumes with and without the first morning void were
calculated. Desmopressin response was defined as greater than 50% reduction in wet
nights. Maximum voided volume with and without first morning voiding was evaluated as
a prognostic factor for desmopressin response.
RESULTS:
Mean ± SD maximum voided volume without first morning void was comparable
between desmopressin responders and nonresponders (230.5 ± 69.3 ml and 219.0 ±
84.8 ml, respectively, p = 0.391). Inclusion of the first morning void demonstrated
responders to have significantly larger values than nonresponders (mean ± SD 296.0 ±
94.0 ml vs 233.5 ± 90.0 ml, p <0.001). When first morning void was included,
desmopressin response was seen in 40% of patients with voided volumes of 65%
expected volume for age vs 10% of patients with volumes less than 65% expected
volume for age.
CONCLUSIONS:
Maximum voided volume can be used as a predictor of desmopressin response only if
first morning voids are taken into consideration. All patients with monosymptomatic
nocturnal enuresis should receive clear instructions to include this measure when
completing frequency-volume charts.
6
Korean J Urol. 2012 Feb;53(2):114-9. Epub 2012 Feb 20.
Diagnostic value of functional bladder capacity, urine osmolality, and daytime
storage symptoms for severity of nocturnal enuresis.
Kim JM.
Source
Department of Urology, Soonchunhyang University Bucheon Hospital, Soonchunhyang
University School of Medicine, Bucheon, Korea.
Abstract
PURPOSE:
To investigate the correlation between functional bladder capacity, first morning urine
osmolality, daytime voiding symptoms, and severity of nocturnal enuresis.
MATERIALS AND METHODS:
We assessed a total of 101 children with nocturnal enuresis (mean age, 7.7±2.3 years).
Patients were divided into three groups according to the severity of enuresis: (1) one to
six episodes per week (46 cases, 45.5%), (2) one episode every day (29 cases, 28.7%),
and (3) multiple episodes every day (26 cases, 25.8%). Baseline parameters were
obtained from frequency volume charts for 2 days, first morning urine osmolality, and a
questionnaire for the presence of frequency, urgency, and daytime incontinence.
RESULTS:
The severity of enuresis increased with younger age (p=0.037) and reduced functional
bladder capacity (p=0.007) and daytime symptoms of frequency and daytime
incontinence (p=0.012, p=0.036). No statistical difference in urine osmolality or urgency
was found among the three groups. Both reduced functional bladder capacity and low
urine osmolality increased according to the severity of enuresis (p=0.012).
CONCLUSIONS:
In children with nocturnal enuresis, severity was increased by younger age, reduced
functional bladder capacity, and the presence of daytime voiding symptoms of frequency
and daytime incontinence. The incidence of small functional bladder capacity was
increased in children with everyday wetting, and the incidences of both small functional
bladder capacity and low urine osmolality were increased in children with everyday
multiple wetting.
7
Pediatr Int. 2012 Feb;54(1):8-13. doi: 10.1111/j.1442-200X.2011.03554.x.
Treatment for nocturnal enuresis: The current state in Japan.
Kaneko K.
Source
Department of Pediatrics, Kansai Medical University, Osaka, Japan.
Abstract
Nocturnal enuresis is common problem in children with a prevalence as high as 20%
among children aged 5. Though nocturnal enuresis does not directly impose imminent
danger to a patient's life, children with enuresis and their parents can be psychologically
suffering in day-to-day life, including in school activities. Therefore, it is important to
provide an explanation regarding the cause of nocturnal enuresis, how to approach the
disorder, the course, and the outlook leading to the planned treatment. The cause of
enuresis is considered to be a mismatch between nocturnal diuresis and nocturnal
bladder capacity, nocturnal polyuria due to a lack of circadian change in antidiuretic
hormones, and a developmental delay in the voiding mechanisms. Therefore, patients
can be classified as the type associated with a large amount of urine at night (polyuria
type), the type that is associated with a functionally small bladder capacity (bladder
type), the type associated with both the aforementioned (mixed type), or the type that
does not fall under any of these (normal type). Based on this logic, although the
International Children's Continence Society has issued the standardization document, in
which the enuresis alarm and desmopressin therapy are recommended as the first line
treatment, a different tack has been taken in Japan, where the therapeutic strategy is
plotted depending on the type of enuresis; pharmacotherapy for enuretic children aged 6
years or older includes desmopressin acetate for polyuria type, anticholinergic agents for
bladder type, and a combination of these agents for mixed type.
8
Urology. 2012 Feb;79(2):428-33. Epub 2011 Dec 22.
Doxazosin Versus Tizanidine for Treatment of Dysfunctional Voiding in Children:
A Prospective Randomized Open-labeled Trial.
El-Hefnawy AS, Helmy T, El-Assmy MM, Sarhan O, Hafez AT, Dawaba M.
Source
Voiding Dysfunction and Urodynamic Section, Urology and Nephrology Center,
Mansoura University, Mansoura, Egypt.
Abstract
OBJECTIVE:
To examine the efficacy and tolerability of tizanidine for the treatment of dysfunctional
voiding in children compared with those of doxazosin.
METHODS:
A total of 40 children with dysfunctional voiding were enrolled in a prospective,
randomized, 2-parallel group, flexible-dose study. The evaluations were performed in
accordance with the International Children's Continence Society guidelines. The children
were followed up after 1 week and then monthly for 6 months for the clinical, urine
culture, and urodynamic parameters. The degree of improvement was assessed using a
satisfaction scale that ranged from 0 (no improvement at all) to 10 (total improvement).
RESULTS:
A total of 40 patients with a mean ± SD age of 7 ± 2.6 years were enrolled. The clinical
and urodynamic parameters were comparable between both groups. At the last followup visit, both groups had had similar improvement in the severity of symptoms,
satisfaction scale, and noninvasive flowmetry parameters. In the doxazosin group, urge
episodes was the only symptom that showed a significant reduction compared with the
baseline values (P = .028). However, the incidence of nocturnal enuresis, urgency
attacks, and daytime incontinence were significantly reduced compared with baseline in
the tizanidine group (P = .003, P = .008, and P = .017, respectively). Adverse effects
were recorded in 6 patients (15%). Epigasteric pain was reported in 2 children (10%)
who received doxazosin. In the tizanidine group, a loss of appetite was noted in 2
children (10%), epigastric pain in 1 (5%), and headache in 1 (5%).
CONCLUSION:
Tizanidine could be a safe and effective treatment of children with dysfunctional voiding
due to pelvic floor/skeletal sphincter dysfunction. More placebo-controlled trails with
larger sample sizes are needed.
9
Urology. 2012 Feb;79(2):421-4. Epub 2011 Dec 14.
Occult megarectum-a commonly unrecognized cause of enuresis.
Hodges SJ, Anthony EY.
Source
Department of Urology, Wake Forest University School of Medicine, Winston-Salem,
North Carolina.
Abstract
OBJECTIVE:
To determine whether occult megarectum remains a commonly unrecognized cause of
enuresis and whether treating it will cure enuresis in most children. A landmark study
proved constipation was a commonly unrecognized cause of enuresis in 1986 in which
constipation was defined as abnormal rectal distension. However, modern
recommendations have focused on signs of functional constipation, such as hard or rare
stools.
METHODS:
A retrospective review of 30 consecutive patients seen in our clinic with a chief complaint
of nocturnal enuresis was performed, with an analysis of the results of their plain
abdominal radiographs. The results of the studies were determined using a novel
method termed the rectal/pelvic outlet ratio and Leech criteria. These results were
compared with the reported constipation history according to the International Children's
Continence Society guidelines, which recommends asking parents and children whether
the child's bowel movements occur less often than every other day and whether the stool
consistency is hard. Patients diagnosed with megarectum were treated with laxatives,
with the goal of restoring normal rectal tone.
RESULTS:
All patients demonstrated rectal distension according to the rectal/pelvic outlet ratio, and
80% were constipated according to the Leech criteria. Only 10% of the patient or
families reported clinical symptoms of constipation. All the adolescent patients in our
study and 80% of the younger patients were cured of enuresis with laxative therapy.
CONCLUSION:
Occult megarectum remains a commonly undiagnosed cause of nocturnal enuresis.
Abdominal radiographs represent a simple, noninvasive method to diagnose
megarectum and might improve the treatment of nocturnal enuresis.
10
J Pediatr Gastroenterol Nutr. 2012 Feb 6. [Epub ahead of print]
Parental Knowledge of Fecal Incontinence in children.
van Tilburg MA, Squires M, Blois-Martin N, Williams C, Benninga MA, Peeters B, Ulshen
M.
Source
*University of North Carolina, Center for Functional GI and Motility Disorders, Chapel
Hill, NC †Duke University Medical Center, Durham, NC ‡Emma Children's Hospital,
Department of Peadiatric Gastroenterology and Nutrition, Amsterdam, The Netherlands.
Abstract
OBJECTIVES:
Fecal Incontinence (FI) is a common and very stressful symptom of constipation in
children. Recurrent FI causes psychological and physiological changes, complicating
treatment as symptom duration progresses. However, parental misconceptions about
the causes of FI may delay seeking medical care. The aim of the present study is to
assess parental knowledge about FI and determine how this relates to the care and
treatment of FI.
METHODS:
A questionnaire was developed from qualitative interviews and clinician input. The
questionnaire was administered to N = 232 parents and tested for reliability and validity.
Subscales were compared between parents who did and did not consult a clinician. In
addition, N = 30 parents completed the questionnaire before and after consultation with a
pediatric gastroenterologist and after 2 months of treatment.
RESULTS:
Two subscales were identified with good psychometric properties: 'Blame & Punish' and
'Worry & Help'. Families who consulted a physician for their child's FI, acknowledged the
role of constipation and scored higher on "Worry& Help" (M = 36.4 vs M = 46.9; p < .0001).
Trends were found for 'Blame & Punish' to decrease after consultation with a pediatric
gastroenterologist (M = 1.7 vs 1.5; p = .08) and after 2 months of treatment (M = 1.5;
p = .08).
CONCLUSIONS:
Parental knowledge about FI changes with physician consultation. These findings can
help in developing educational materials for parents to encourage early diagnosis and
treatment and prevent chronic problems that are difficult to manage.
11
J Pediatr Gastroenterol Nutr. 2012 Feb 29. [Epub ahead of print]
Characteristics of Intestinal Habits In Children Under Four Years of Age: Detecting
Constipation.
Mota DM, Barros AJ, Santos I, Matijasevich A.
Source
*Department of Mother and Child Health, Federal University of Pelotas †Graduate
Program in Epidemiology, Federal University of Pelotas ‡Department of Social Medicine,
Federal University of Pelotas.
Abstract
OBJECTIVES:
To describe the prevalence of childhood constipation, stool characteristics and their
relationship with toilet training and age of introduction of cow's milk.
METHODS:
A total of 4231 children born in 2004, from a birth cohort study, were assessed at 12, 24
and 48 months of age, when their mothers provided information on sociodemographic
characteristics, bowel habits, toilet training and age of introduction of cow's milk and
other foods.
RESULTS:
The prevalence of constipation was 27.3% and 31.0% at 24 and 48 months of age,
respectively. Among girls, at 48 months of age, it was 34.4% vs. 27.4% in boys
(p < 0.001). The most common features of constipation were scybalous stools (47.7%
and 41.0% at 24 and 48 months, respectively), evacuation difficulty (24.3% and 23.1%)
and hard stools (17.8% and 34.1%). Toilet training starting before 24 months was
associated with constipation at 24 months and its persistence up to 48 months. Among
children who did not receive cow's milk in their first year of life, 22% had constipation at
24 months, 22.6% at 48 months and 8.3% at 24 and 48 months. Among children who
started cow's milk before 30 days of life, the respective proportions of children with
constipation was 28.2%, 33% and 12.4%.
CONCLUSION:
The prevalence of constipation increases with age and cannot be detected using only
information on evacuation interval. Toilet training before 24 months and introduction of
cow's milk before 1 year of age is positively associated with constipation at 24 months
and its persistence up to 48 months.
12
Acta Paediatr. 2012 Feb 21. doi: 10.1111/j.1651-2227.2012.02632.x. [Epub ahead of
print]
The care of constipated children in primary care in different countries.
Burgers R, Bonanno E, Madarena E, Graziano F, Pensabene L, Gardner W, Mousa H,
Benninga MA, Di Lorenzo C.
Source
Emma Children's Hospital, Amsterdam Medical Nationwide Center, Amsterdam,
Netherlands ChildrenDepartment of 's Hospital, Columbus, OH, USA Pediatrics,
University of 'Magna Graecia', Catanzaro, Italy.
Abstract
To investigate and compare the approach to childhood Aim: constipation by primary
care physicians (PCP) in three Western countries to give insight into adherence to
current guidelines and in Prospective study utilizing a two-page survey regarding actual
care. Methods: the approach to children suspected to have functional constipation (FC).
A total of 413 of 1016 (41%) distributed surveys were returned out of which 383 were
suitable for analysis. Surveys were answered anonymously. Survey responses were
analysed and In Italy, the Netherlands, and the are reported in a descriptive way.
Results: USA, respectively, 75, 187 and 121 surveys were returned by PCP. The
majority of PCP (62%) considered stool withholding as a result of painful defecation to
be the most common cause of childhood constipation. Rectal examination was used as
a standard diagnostic tool for the evaluation of FC by only 31% of PCP with significant
differences among the countries (p<0.05) and a minimum in the Netherlands (11%).
Abdominal X-ray is used by 49% to diagnose FC. 63% of PCP were convinced that
hard stool can be softened by drinking more water. Polyethylene glycol was the most
common prescribed drug (85%). Significant differences were found among countries in
the use of senna and bisacodyl suppositories (p< Significant differences 0.05).
Conclusion: in practice exist among PCP from different countries regarding the
performance of a digital rectal examination, need for additional diagnostic tests and use
of laxatives in childhood constipation.
13
J Pediatr. 2012 Feb 14. [Epub ahead of print]
Value of Abdominal Radiography, Colonic Transit Time, and Rectal Ultrasound
Scanning in the Diagnosis of Idiopathic Constipation in Children: A Systematic
Review.
Berger MY, Tabbers MM, Kurver MJ, Boluyt N, Benninga MA.
Source
Department of General Practice, University of Groningen, University Medical Center,
Groningen, The Netherlands.
Abstract
OBJECTIVE:
To perform a systematic review evaluating the value of abdominal radiography, colonic
transit time (CTT), and rectal ultrasound scanning in the diagnosis of idiopathic
constipation in children.
STUDY DESIGN:
Eligible studies were those assessing diagnostic accuracy of abdominal radiography,
CTT, or rectal ultrasound scanning in children suspected for idiopathic constipation.
Methodological quality of the included studies was assessed with the Quality
Assessment of studies of Diagnostic Accuracy included in Systematic reviews checklist.
RESULTS:
One systematic review summarized 6 studies on abdominal radiography until 2004. The
additional 9 studies evaluated abdominal radiography (n = 2), CTT (n = 3), and
ultrasound scanning (n = 4). All studies except two used a case-control study design,
which will lead to overestimation of test accuracy. Furthermore, none of the studies
interpreted the results of the abdominal radiography, ultrasound scanning, or CTT
without knowledge of the clinical diagnosis of constipation. The sensitivity of abdominal
radiography, as studied in 6 studies, ranged from 80% (95% CI, 65-90) to 60% (95% CI,
46-72), and its specificity ranged from 99% (95% CI, 95-100) to 43% (95% CI, 18-71).
Only one study presented test characteristics of CTT, and two studies presented test
characteristics of ultrasonography.
CONCLUSION:
We found insufficient evidence for a diagnostic association between clinical symptoms of
constipation and fecal loading on abdominal radiographs, CTT, and rectal diameter on
ultrasound scanning in children.
14
MBio. 2012 Feb 14;3(1). pii: e00019-12. doi: 10.1128/mBio.00019-12. Print 2012.
A microbial association with autism.
Benach JL, Li E, McGovern MM.
Source
Departments of Molecular Genetics and Microbiology, Medicine and Pediatrics, Stony
Brook University, Stony Brook, New York, USA.
Abstract
ABSTRACT Autism is a heterogeneous group of complex developmental disabilities that
result from a number of possible etiologies. There are a well-known number of
comorbidities associated with autism spectrum disorders (ASD), including, commonly,
gastrointestinal (GI) pathology, which can include variable combinations of constipation,
diarrhea, abdominal pain, gastroesophageal reflux, and vomiting. An American Academy
of Pediatrics consensus panel has recommended that prospective studies be carried out
to determine the prevalence of GI disorders in ASD and their pathophysiologic basis. In
a recent article, Williams et al. [B. L. Williams, M. Hornig, T. Parekh, and W. I. Lipkin,
mBio 3(1):e00261-11, 2012] have provided one such study of autism with GI
comorbidities by presenting evidence of Sutterella species in ileal mucosal biopsy
specimens from patients diagnosed with ASD but not in control children with GI
symptoms, suggesting a specific role for Sutterella in ASD. Sutterella sequences
represented ~1 to 7% of the total bacterial sequences, and this is a very large effect size
on the ileal mucosal composition of the autism phenotype, rivaling or perhaps exceeding
the effect size of the ileal Crohn's disease phenotype. This study opens a new field of
investigation to study the etiology or consequences of GI comorbidities in ASD.
15
J Pediatr Gastroenterol Nutr. 2012 Feb;54(2):258-62.
Do oro-anal transit markers predict which children would benefit from colonic
manometry studies?
Tipnis NA, El-Chammas KI, Rudolph CD, Werlin SL, Sood MR.
Source
Department of Pediatrics, Division of Pediatric Gastroenterology, Medical College of
Wisconsin, Milwaukee, WI, USA. ntipnis@mcw.edu
Abstract
OBJECTIVES:
The aim of the study was to compare oro-anal transit time (OTT) measured by radioopaque markers with colon motility (CM) findings in children with chronic constipation
and to assess clinical outcomes in children with chronic constipation evaluated by OTT
and CM studies.
METHODS:
Twenty-four children with chronic constipation (12 girls; median age 12 years [3-18
years]; median symptoms 87 months [6-186 months]) who underwent OTT and CM
studies were reviewed. The OTT was determined using commercially available
Sitzmarks. Patients were studied for a median of 23 months (4-60 months) and
outcomes reviewed.
RESULTS:
All 5 children with normal OTT had normal CM; however, only 47% (9/19) of children
with slow OTT had an abnormal CM. The abnormal CM findings were total colonic
pseudo-obstruction in 3 and left colonic pseudo-obstruction in 6 children. Of the 9
children with abnormal CM, 5 were managed surgically, 1 with medicine escalation, and
3 were lost to follow-up; all 6 children with known follow-up have more bowel movements
and less soiling. Of the 15 children with normal CM, 10 were managed with medication
escalation, 3 with behavioral intervention, and 2 surgically. Of these 15 children, 8
improved, 1 did not change, 2 worsened, and 4 were lost to follow-up.
CONCLUSIONS:
OTT studies may be helpful to predict which children should be referred for CM studies.
Normal OTT studies may predict normal colon manometry; however, abnormal OTT
studies may not predict abnormalities in colonic manometry in children with chronic
constipation. Therefore, patients with slow transit marker studies should be assessed by
colon manometry to evaluate colon neuromuscular integrity.
16