Constipation and functional faecal retention in a group of school children in a district in Sri Lanka

Objective To assess the prevalence of constipation and functional faecal retention among a group of school children in Gampaha district of Sri Lanka. Method This is a cross sectional survey. A validated, self-administered questionnaire was distributed to randomly selected children, aged 1016 years, in a semi-urban school in Gampaha District of Sri Lanka. Constipation was defined using Rome III criteria and Paris Consensus on Childhood Constipation Terminology (PACCT). Functional faecal retention was diagnosed using Rome II criteria. Results A total of 441 questionnaires were distributed and 429 (97.3%) responded (53.1% males, mean age 12.4 years, SD 1.5 years). According to Rome III criteria and PACCT, 46 (10.7%) had constipation. Prevalence of constipation was higher in males (14.5%) compared to females (6.5%) [OR 2.45, 95% CI 1.19-5.1, p=0.012]. Twenty three (5.4%) had functional faecal retention. Conclusions Chronic constipation is a significant problem, affecting approximately 10% of children in a semi-urban school in Gampaha district. It is commoner among males. Both Rome III criteria and PACCT are effective in diagnosing childhood constipation in epidemiological studies.


Introduction
Constipation is a global health problem, affecting children and adolescents, which has a great impact on quality of life of both affected children and parents.The prevalence of constipation varies from 0.7 in Italy to 29.6 in Hong Kong 1 .It accounts for approximately 3% of visits to general paediatric _________________________________________ 1 Senior lecturer in Paediatrics, 2 Senior Lecturer in Physiology, 3 Lecturer in Paediatrics, 4 Demonstrator in Physiology, 5 Demonstrator in Paediatrics, Faculty of Medicine, University of Kelaniya (Received on 23 July 2008.Accepted after revision on 27 February 2009) clinics 2 and 25% visits to gastroenterology clinics 3 .Up to date, there is no data on the prevalence of this important clinical problem among Sri Lankan children.It has been widely studied in the west, but to date there is a scarcity of epidemiological data from the developing word.This has led to the false belief that it is a disease of the western world.
Due to lack of a uniform definition, diagnosing constipation had been an extremely difficult task in clinical and epidemiological studies.To overcome this problem, Rome II group have defined criteria for diagnosing constipation and functional faecal retention.These criteria define constipation only in infants and toddlers and functional faecal retention is diagnosed only in older children 4 .In subsequent studies, these criteria were shown to be too restrictive in diagnosing defaecation disorders in children 5,6 and therefore, the Paris Consensus for Childhood Constipation Terminology (PACCT) group introduced a new definition in 2005 7 .In 2006, Rome II criteria were revised and the new Rome III criteria for paediatric constipation were introduced 8 .
The objectives of this study were to study the prevalence of constipation and functional faecal retention among a group of school children from Gampaha district and clinical features associated with them.

Method
This is a cross sectional survey carried out in a semi-urban school in Gampaha district of Sri Lanka.Five classes were randomly selected from the academic years 6 to 10 and all students (10-16 years) in the selected classes were included in study.A validated, self administered questionnaire was distributed and was filled under the guidance of research assistants.Details of bowel habits during the previous 3 months were collected along with information on demographic features and family history of constipation.The presence of associated symptoms (e.g.abdominal pain, nausea, vomiting etc.) were also noted.Constipation was defined using Rome III criteria 8 (Table 1) and the Paris Consensus of Childhood Constipation Terminology (PACCT) group guidelines 7 (Table 1).Functional faecal retention was defined using Rome II criteria 4 (Table 2).Consistency of stool was determined using Bristol stool chart 9 .

Rome III diagnostic criteria for constipation
Paris consensus for childhood constipation terminology 2 or more of the following criteria fulfilled in a child of at least 4 years, once per week for at least 2 months This study was approved by the Ethical Review Committee of the Sri Lanka College of Paediatricians.

Results
A total of 441 questionnaires were distributed and 429 (97.3%) responders were included in final analysis (males 53.1%).Ages ranged from 10-16 years with a mean age of 12.4 years (SD 1.5 years) [males 12.4 years (SD 1.51 years) and females 12.4 years (SD 1.52 years)].

Prevalence of constipation and functional faecal retention
According to Rome III and PACCT criteria, 46 (10.7%) had constipation (Table 3).The mean age of children with constipation was 10.6 years (SD 2.6 years) [males 12.01 years (SD 1.53 years), females 12.5 years (SD 1.63 years)].Constipation was more common in males (p=0.01).The distribution of children with constipation according to age groups and sex is shown in the Figure 1.
During analysis, the 46 children who fulfilled the criteria for constipation were compared with 375 healthy children without defaecation disorders (controls).According to Rome II criteria 23 (5.4%) had functional faecal retention [mean age 12.1 years, SD 1.72] (Table 3).

Clinical features associated with constipation
Factors associated with constipation are presented in Table 4. Constipation was significantly higher in those with a family history of constipation.

Table 2 Rome II diagnostic criteria for functional faecal retention
From infancy to 16 years old, a history of at least 12 weeks of

Discussion
Prevalence of constipation and functional faecal retention in our study sample of school children aged 10-16 years were 10.7% and 5.4% respectively.Constipation was more common in males, and those with a positive family history.Vomiting, weight loss, straining, bleeding per rectum, and perianal fissures were more common in the affected children.
Considering the high prevalence of constipation, its impact on lives of patients, parents and family members, and its burden on health care system, little was known of its epidemiology in developing countries including Sri Lanka.Prevalence of constipation varies around the world.In agreement with our results, Uguralp et al. have reported constipation in 12.4% of Turkish school children in Malatya district 10 .Studying preschool children from Eastern district of Hong Kong, Ip et al found 29.6% of them having constipation 11 .In Rio de Janeiro, Brazil 28% of school children were noted to be having constipation 12 .However, in contrast to common belief, lower prevalence of constipation has been reported in some western studies.In USA a single clinic based study reported constipation in 3.2% of children 13 .
The differences in the prevalence of constipation in various studies cited above are due to several factors, but mainly due to the variations of definitions used by the researchers.For example de Arajuo Sant' Ann and Calcado had defined constipation as difficulty during defaecation often or sometimes 12 which may be found in children without constipation.Ip et al. used Rome II criteria 11 .However, given the restrictive nature of the Rome II criteria in diagnosing defaecation disorders, the prevalence is very high in Hong Kong.Furthermore, low prevalence found by Leoning-Boucke may also be due to the selection of the sample from the children attending to a general paediatric clinic 13 .Finally the differences in the prevalence rates may be due to cultural, racial environmental and socio-economic conditions.Therefore, more robust definition and better sampling frames are necessary to identify the precise epidemiology of this important public health problem.
To date, only one community based study has assessed prevalence of functional faecal retention.Functional faecal retention is only defined in Rome II criteria and therefore studies before 1999 do not recognize it.Uc et al. studied 243 African American children attending to a single community clinic found only 1 (0.4%) child with this condition 14 .We found functional faecal retention in a higher percentage of children (5.4%).Inadequate toilet facilities in schools, which are frequently unhygienic, often lead to stool withholding and therefore functional faecal retention.Prevalence of constipation was significantly higher in males in our study.Contrary to this, two studies from Asia reported higher prevalence of constipation among females 11 .Several other studies found no sex difference in this condition 10,15,16 .We did not find a significant difference in prevalence of functional faecal retention in males and females.Sex difference of functional faecal retention has not been studied in the world.
Even though straining is not a diagnostic criterion for constipation, it was seen in approximately 75% of Sri Lankan children with constipation.This is higher than reported in previous studies (35%) 17 .Therefore, we feel that straining should be included as a diagnostic criterion for childhood constipation.Abdominal pain and distension, anorexia, vomiting, blood streaked stools and urinary tract infection and enuresis are common symptoms associated with constipation 12,17,18 .Similar to previous studies, bleeding per rectum, vomiting, weight loss and perianal fissures were more common in the affected children in our study.
We found a significant association between constipation and the presence of similar disease among first degree relatives, a finding reported previously 11,19 .Furthermore, the concordance for constipation was reported to be six times greater among identical twins than among fraternal twins 20 .The genetic and environmental vulnerability of constipation needs further clarification to identify a definite genetic predisposition.
In conclusion, constipation is seen approximately 10% of school children aged 10-16 years in our study sample.Functional faecal retention is seen in nearly half of them.An island-wide survey is urgently needed to assess the prevalence, risk factors and associated features of constipation in Sri Lanka.Availability Rome III and PACCT criteria provide a firm platform for diagnosing paediatric defaecation disorders.This will facilitate studies on paediatric constipation and will generate more applicable epidemiological data worldwide.

• 2 •
or fewer defaecations per week • At least 1 episode of faecal incontinence per week • Retentive posturing or excessive volitional stool retention • Presence of large faecal mass in the rectum • History of large diameter stools that may obstruct the toilet • Painful or hard bowel motions At least 2 of the following criteria fulfilled for at least 2 months Frequency of bowel movements <3 per week • More than one episode of faecal incontinence per week • Retentive posturing and withholding behaviour • Large stool in the rectum or palpable on abdominal examination • Passing stools so large that they may obstruct the toilet • Painful defaecation Data was analysed using Fisher exact test and χ2 test [EpiInfo 6, version 6.04 (1996), Centres of Disease Control and Prevention, Atlanta, Georgia, USA and World Health Organization, Geneva, Switzerland].P<0.05 was considered significant.
Passage of large diameter stool at intervals <2 times per week and • Retentive posturing, avoiding by purposefully contracting the pelvic floor.As pelvic floor muscles fatigue the child uses the gluteal muscles, squeezing the buttocks together