Constipation is a common disorder in childhood throughout the world. The reported prevalence of constipation in children ranges widely, from 0.7% to 29.6%, with a median value of 16% (1). Different rates of prevalence are dependent on the criteria used to define constipation. Constipation can have a huge effect on children's quality of life and place a significant burden on primary and secondary care. Thus, chronic constipation should be considered a major public health issue in the pediatric population, and knowledge of its definition, causes, and management is highly relevant to pediatric care providers.
The World Congress Working Group suggested that “constipation is a symptom defined by the occurrence of any one of the following, independent of stool frequency: passage of hard, pebble-like, or cracked stools; straining or painful defecation; passage of large stools that may clog the toilet; or stool frequency <3 per week, unless the child is breast-fed.” At times, chronic constipation (symptoms for at least 2 weeks) presents as recurrent abdominal pain, enuresis, nonstructural urinary tract infections, or fecal soiling (2). Although several internationally accepted guidelines, such as those of the Paris Consensus on Childhood Constipation Terminology (3) and the Rome III criteria (4), have been developed to provide symptom-based diagnostic criteria for constipation, none of these guidelines have been implemented worldwide in clinical practice yet. Constipation guideline committees were also formed by the National Institute for Health and Clinical Excellence (NICE) (5) and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) (6) to develop clinical practice guidelines. Rome III criteria and NASPGHAN guidelines are the guidelines most commonly used in Saudi Arabia.
One of the assessment measures to determine the effectiveness of campaign messages is to conduct knowledge and practice styles (KPS) surveys of pediatric providers (PPs). Understanding the spectrum of management styles used in the care of children with constipation would be paramount for improving quality of care, having a positive effect on a child's quality of life, achieving better health outcomes, and reducing overall health care costs.
The majority of children who experience constipation and whose caregivers seek medical care are seen by pediatric care providers such as pediatricians, general practitioners (GPs), or family physicians (FPs). The Saudi health care system provides a wide range of preventive and curative health services to the whole population and the majority of children are seen by general pediatricians. There are few studies comparing the KPS of health care providers regarding the approach to children with difficult defecation. Burgers et al (7) showed that significant differences in practice exist among primary care physicians from different countries (Italy, the Netherlands, and United States) regarding evaluation and treatment of childhood constipation. Another recent study suggested that up to 86% of primary care physicians in West Virginia had no awareness of the published clinical guidelines for constipation in children (8).
To the best of our knowledge, ours is the first study in Asia to evaluate KPS of pediatricians regarding childhood constipation. The aims of our study were to evaluate KPS among PPs working in 5 regions of Saudi Arabia and to compare their approach to childhood constipation to give insight into adherence to present guidelines.
Participants were asked to complete the KPS constipation questionnaire if they were PPs. A PP was defined as a pediatrician or physician involved in clinical care, research, or teaching related to pediatric medicine. Pediatricians were defined as pediatric specialists (PSs) and pediatric consultants (PCs), whereas other physicians were defined as GPs and FPs.
This cross-sectional national survey was conducted in 5 regions of Saudi Arabia: central region (CR), western region (WR), eastern region, northern region, and southern region. Saudi Arabia's population is 27 million and children ages 0 to 14 years represent 29.4% of the population. The Ministry of Health is the major government agency offering free health care coverage for Saudi citizens in 5 regions. Private hospitals contribute to the delivery of health care services equally to 5 regions of Saudi Arabia. There is no difference among the 5 regions regarding distance to travel to access a physician. Saudi Arabia is one of the driest countries in the world and the climate of 5 regions is marked by harsh, dry desert with great temperature extremes (high temperatures during the day and low temperatures at night), with the exception of the southern region. The survey population consists of members listed as PPs by the Saudi Pediatric Association, the Saudi Commission for Health Specialties, and the Ministry of Health. These criteria resulted in an initial target cohort of approximately 2100 members. From this cohort, a random sample of 850 members was obtained.
We designed a brief, user-friendly questionnaire that assessed the KPS of PPs regarding the diagnosis and management of constipation. The KPS constipation questionnaire was pilot tested by a sample of pediatric gastroenterologists (PGs). The questionnaire was then revised based on reproducibility, validity, and question value. An initial pool of items was evaluated for content and understandability by a group of clinicians (7 PGs and 5 pediatric practitioners). Changes and modifications were made based on the pilot results. The survey was administered during a 6-month period from January to June 2012 via 2 mechanisms: direct communication and e-mail to enhance response rates. Most of the participants were interviewed face-to-face using an English-language questionnaire, whereas few participants completed the questionnaire by e-mail. The distribution of the surveys varied for the individual regions. Most of the surveys were distributed among the attendees at local conferences, and some surveys were distributed to institutions. A cover letter was attached with a brief explanation of the study. The letter stated that the survey was anonymous, that physicians’ identities would not be part of the research record, and that no information in the questionnaire was used to ascertain identity. The estimated time to complete the survey was approximately 20 minutes.
The questionnaire consists of 25 items in 5 subscales: demographics and practice characteristics (7 items); definition, causes, and diagnosis of constipation (6 items); constipation management (6 items); family concerns regarding their constipated child (3 items); and source of constipation-related information (3 items).
Some response options were on a scale: all of the time, most of the time, sometimes, seldom (rarely), and never. Some of the response items were categorized as yes or no. Some of the items asked participants to choose the best answer.
Demographics and Practice Characteristics
Participating PPs were asked for their age, title, sex, region of practice, type of practice (general or subspecialty), and level of health care institute to identify potential differences in treatment practices that may be influenced by the number of years in practice and availability of medications.
Definition, Causes, and Diagnosis of Constipation
Participants were asked to provide the definition of constipation. The respondents were queried as to the most common cause of constipation. Participants were also surveyed as to whether they ordered diagnostic tests for childhood constipation.
Management of Constipation
Respondents were asked to provide information concerning the most frequently used laxative agent in their practice. Participants were also surveyed to ascertain knowledge of the main management options for chronic constipation, the duration of treatment, and timing for referral to PGs.
Family Concerns Regarding Their Constipated Child
The participants were asked whether they were aware of family concerns about factors related to constipation (stricture and malignancy) or persistence of the condition into adulthood. Respondents were asked whether they provided information to the child or parent such as reward stars, behavioral modification, or drawing diagrams to explain the mechanism of defecation.
Source of Constipation-Related Information
Participants were asked whether they had childhood constipation–related information available to them. The participants were asked to rank the best source of constipation-related information that they used from a list that included medical journals, conferences, newsletters, Internet, and pharmaceutical company–sponsored symposia. Finally, the participants were asked whether they attended a seminar or any activity addressing the problem of constipation in children in the previous 6 months.
Statistical analyses were performed using Stata/IC 12.1–2011 software (StataCorp LP, College Station, TX). The percentage of participants who responded to each question was determined. χ2 and Fisher exact tests were used to compare categorical variables between groups. Student t tests were used to compare between continuous variables between groups. The results were considered significant if P < 0.05.
The ethics committee of King Abdullah International Medical Research Center approved the study. The recipients were considered to have consented if they filled out the questionnaire. All of the information collected was kept strictly confidential.
Of the 850 questionnaires distributed to PPs, 622 (response rate 73%) were completed and analyzed. Sixteen questionnaires were excluded because of missing or incomplete data. A majority of the respondents were boys (n = 398; 64%). The majority of participants (63%) were between 30 and 50 years old. Among them, 24% were PCs, 40% were PSs, 18% were GPs and FPs, and 2% were PGs. Demographic and practice characteristics of the study participants are listed in Table 1.
Definition, Causes, and Diagnosis of Constipation
When survey respondents were asked about the definition of constipation, 319 of 521 respondents (61.2%) were aware of the Rome criteria definition of functional constipation. There was no significant difference in reporting the correct definition of the Rome criteria of constipation between pediatricians (PSs and PCs) and physicians (GPs and FPs) (63% vs 60.1%; P > 0.05). PPs working in WR reported the correct definition of the Rome criteria of constipation significantly more than those working in CR (69.0% vs 53.8%; P = 0.010). Only 63.1% of government physicians and 50.6% of private physicians were aware of the Rome criteria definition of constipation.
When survey respondents were asked about the cause of constipation, 27% of pediatricians, 24.0% of physicians, and 50% of PGs reported that stool withholding is the most common cause of constipation, but there were no significant differences among groups (P > 0.05). Forty percent of pediatricians and 36.5% of other physicians believed that painful anal fissure was the most common cause of stool withholding. Correlation between responders’ status and definition and causes of constipation is shown in Table 2.
Among the PPs who responded to the survey, 39% reported performing rectal examinations routinely in the evaluation of the child with constipation. There were significant differences in the percentage of participants in different geographic regions who performed rectal examinations (P < 0.05), with a maximum in WR and a minimum in the eastern region. There were no significant differences in performance of rectal examinations between pediatricians and other physicians. There were significant differences in the performance of rectal examinations between PPs and PGs (39.0% vs 78.6%; P = 0.009). Thirty-four percent of all respondents ordered abdominal x-rays in the assessment of chronic constipation. Correlation between responders’ status and practice style regarding diagnosis and management of constipation is shown in Figure 1.
Management of Constipation
The most common laxative agent used by all PPs for treatment of chronic constipation was lactulose, and docusate sodium was the laxative least often prescribed. Pediatricians (PSs and PCs) prescribed lactulose significantly more often than other physicians (GPs and FPs) (89.3% vs 69.2%; P = 0.001). Other physicians prescribed glycerin suppositories significantly more than pediatricians (P = 0.007). Multiple laxative agents prescribed by all providers are shown in Figure 2. The durations of laxative treatment for chronic constipation were 1 month (45%), 2 months (14%), 3 months (18%), 4 months (7%), and >6 months (15%).
Pediatricians reported using rectal disimpaction (clean-out) before maintenance treatment for chronic constipation significantly more than other physicians (47.1% vs 18.6%; P = 0.001) (Fig. 1). In response to questions about strategies for the management of the more challenging cases of chronic constipation, 9.8% reported that they would maximize laxative dose, 22.2% would add or change to another laxative class, 19.5% would encourage dietary changes, 39.9% would refer to a PG, and 8.7% would refer to a pediatric surgeon. No significant differences were found between pediatricians and other physicians regarding management of refractory chronic constipation (Fig. 3).
Family Concerns Regarding Their Constipated Child
Different treatment strategies were used by the study participants. Study participants were asked to mark whether they addressed parental/family concern all of the time, most of the time, sometimes, seldom (rarely), or never. Twenty-nine percent of respondents sometimes used a diagram or a personal drawing to explain the mechanism of defecation, whereas 26% never used a diagram. A plurality of respondents (43%) believed that nonmedical treatment (rewarding stars and behavioral modification) could help in the management of constipation. Correlation between responders’ status and parental/family concerns about constipation is shown in Table 3.
Additional questions focused on respondents’ specific knowledge of parental/family concerns about the complications and predisposing factors of constipation. Forty-five percent reported no concerns and that most parents think constipation is functional in nature, 23% reported concerns that constipation was caused by stricture, 22% reported concerns that constipation would persist into adulthood, and 10% reported concerns that constipation was caused by a malignancy.
Source of Constipation-Related Information
More than half of the respondents expressed the concern that the amount of childhood constipation–related information was not enough. In response to the question of how respondents obtained information about chronic constipation, 31.2% reported obtaining information from medical journals, 17.9% from conferences, 5.6% from newsletters, 38.6% from the Internet, and 6.8% from pharmaceutical company–sponsored symposia. The majority of respondents (84.6%) had not attended a seminar or any continuing medical education (CME) activity pertaining to chronic constipation in the previous 6 months.
Additional questions focused on respondents’ KPS of chronic constipation. There were significant differences in the percentage of participants in different age groups in reporting the correct definition of constipation (P < 0.05), with a maximum in 30 to 50 years of age and a minimum in older than 50 years. Correlation between responders’ status and practice style regarding their age and the type of institution is shown in Table 4.
To our knowledge, this is the largest study describing pediatricians’ KPS regarding childhood constipation. Burgers et al (7) surveyed 413 primary care physicians from different countries (Italy, the Netherlands, and United States) and reported that significant differences in practice existed among them regarding the performance of digital rectal examinations, need for additional diagnostic tests, and use of laxatives in childhood constipation. The present study took a novel approach in that it gathered information about personal experiences with KPS. More than half of the survey respondents were from WR and CR of Saudi Arabia, which reflects the geographic distribution of pediatricians and other physicians in Saudi Arabia.
In a recent analysis by Everhart and Ruhl (9), constipation was the second most common ambulatory care diagnosis, after gastroesophageal reflux disease. Arguably, constipation has not received the public health attention it deserves, especially in children. Van Ginkel et al (10) showed that one-third of children with constipation continue to experience constipation into adolescence and early adulthood. Therefore, children and adults may present repeatedly for constipation for a prolonged period, a factor that likely contributes to the incremental costs of health care.
In the present study, participants were considered as correctly defining constipation if they used a definition that was consistent with the Rome III diagnostic criteria (4). In our study, most of the participants were able to define constipation easily with no significant differences between pediatricians and other physicians; however, significant differences in knowledge were noted between PPs from different regions in Saudi Arabia regarding the definition and cause of constipation. These data may be explained by lack of educational materials and different access to resources in some regions of Saudi Arabia.
A minority of primary care physicians (28.7%) were aware of and used the Rome criteria definition for diagnosis of chronic constipation (11). In our study, 61.2% of PPs were aware of the Rome criteria definition of chronic constipation.
Burgers et al (7) demonstrated that rectal examination was used as a standard diagnostic tool for the evaluation of constipation by 31% of health care providers, a similar figure found in our survey, with 39% of PPs claiming to be performing a rectal examination in the evaluation of constipation. Our data demonstrated no significant differences between pediatricians and other physicians regarding performance of rectal examinations, but there were significant differences in this practice pattern among the 5 regions of Saudi Arabia.
According to the NICE guidelines, an abdominal radiograph is not recommended to diagnose functional constipation in children, although occasionally a plain abdominal x-ray may be useful in the evaluation of constipation of uncertain etiology (12). Our study showed that 34% of PPs used abdominal x-rays to diagnose functional constipation in children. This percentage could be explained by participants’ lack of knowledge of NICE or NASPGHAN guidelines.
Treatment of childhood constipation is mostly based on clinical experience rather than on published clinical trials because of a lack of randomized controlled studies (13). The objectives of treating children who have constipation are to restore a regular defecation pattern (soft and painless stools) without fecal incontinence and to prevent relapses. Four important steps in the treatment of childhood constipation have been recommended: education, disimpaction, prevention of reaccumulation of feces, and close follow-up (6). Fecal disimpaction before maintenance treatment with oral and/or rectal laxatives is recommended to increase success and reduce the number of fecal incontinence episodes (6). Our study demonstrates that the majority of respondents (67.4%) performed a fecal disimpaction before maintenance treatment for chronic constipation. This is a figure higher than of Borowitz et al (14), who reported that 45% of physicians prescribed disimpaction followed by daily laxatives. Burgers et al (7) reported that disimpaction was not consistently performed before the initiation of maintenance therapy, with 20% always and 47% sometimes performing a disimpaction.
The decision regarding which laxative to use is based on a combination of safety, cost, child's choice, ease of administration, and the treating physician's preference (15). A recent Cochrane Review found that polyethylene glycol and lactulose are the most frequently used laxatives for the treatment of constipation (16). Our study found that multiple laxatives were used for treatment of chronic constipation. The participants in our survey used lactulose most frequently followed by glycerin suppositories. Based on a systematic review by Pijpers et al (17), no recommendations can be made to support the use of one laxative over another for treatment of childhood constipation.
A systematic review found that only 50% of children with functional constipation were successfully treated and taken off laxatives after 12 months of intensive treatment in either general pediatric or pediatric gastroenterology settings (18). Our study showed that 45% of respondents prescribed medication for <1 month, whereas 15% of them prescribed medication for >6 months. These data may be explained by the lack of participants’ knowledge of guidelines for the treatment of childhood constipation.
Parental/family education regarding understanding of the etiology, symptoms, and principles of management remain critical in achieving success. Management should start with explaining the physiological basis of constipation and fecal incontinence to the child and family. NICE guidelines recommend that the child should never be blamed for soiling, and this point should be explained to parents (19). Our study showed that many participants never or rarely used a diagram or personal drawing to explain the mechanism of defecation to the family. The results of our study also showed broad differences in educational approaches to childhood constipation among PPs. We found that 45% of parents or families have no concern and believe that constipation is functional in nature.
It was discouraging to find that more than half of the pediatricians and physicians in the study did not have enough information and education regarding childhood constipation. The majority of respondents had not recently attended a seminar or a CME activity pertaining to chronic constipation. Kamm et al (20) concluded that further education about constipation is necessary for both gastroenterologists and primary care physicians. On the basis of survey results, we recommend the incorporation of formal training and didactics for GPs and FPs during residency training, and the addition of regularly occurring CME activities.
The strengths of our study are that the study is cross-sectional, the survey was conducted in all regions of Saudi Arabia, and most questionnaires were filled out under the supervision of the investigators to avoid misinterpretation of the questions. This study has several limitations. There may be some response bias—PPs who have a special interest in constipation may have been more likely to respond to the survey. Thus, the state of knowledge of chronic constipation among PPs may be even lower than that reported in this study. The PSs and PCs in our sample demonstrated a higher response rate than GPs and FPs, possibly because of more interest or more exposure to defecation disorders.
In summary, this is the largest survey study of KPS of pediatricians, other physicians, and PGs regarding childhood constipation. Our data support the findings of previous studies (7,8) showing broad differences in knowledge and diagnostic and therapeutic approaches to childhood constipation among PPs within and between different regions. This survey may provide motivation to researchers in other regions to assess the present state of awareness and knowledge of chronic constipation and to formulate recommendations for the management of chronic constipation.
The following conclusions are drawn from this study:
1. This study provides valuable insight into the KPS regarding chronic constipation and its management by PPs working in Saudi Arabia.
2. Significant differences in knowledge gap and practice patterns exist among PPs from different regions of Saudi Arabia regarding the definition and the cause of constipation, performance of rectal examination, use of laxatives therapy, and management of childhood constipation.
3. The identification of gaps in knowledge and practice may be helpful to policymakers who are in charge of developing educational materials for physicians and pediatricians about diagnosis and treatment of chronic constipation in children.
The authors thank all of the pediatric providers for participating in the survey.