What Is Known
- A well prepared bowel for colonoscopy directly impacts the success of the procedure, the risk of adverse events, and the interpretation of the findings.
- Pediatric bowel preparation can be challenging, given the unpalatable taste of the medication, the requirement for clear liquid diet, and the adverse effects.
What Is New
- Facilitators to a good bowel preparation include providing families with both verbal and written instruction, ensuring easy communication with the gastroenterology team, and keeping parents involved and motivated for success.
- Barriers to a good bowel preparation include parental confusion regarding mixing of the preparation, a lack of clarity on expected stool end goals, and lack of familiarity of pharmacists with pediatric bowel preparation.
The number of children undergoing colonoscopy continues to increase in pediatric gastroenterology (GI), and a well-prepared bowel for colonoscopy is of utmost importance. It has a direct impact on the success of the procedure, the interpretation of the findings, and the need for repeat procedure. Inadequate bowel preparation may be associated with missed diagnoses, procedure-related complications, and increased resources (1–3). In both the pediatric and adult literature, up to one-third of the colonoscopies have been associated with suboptimal bowel preparation (4,5).
Studies have been conducted in the adult population to assess factors contributing to improved bowel preparation. These studies have shown that educational booklets and cartoon aids, as well as telephone re-education before colonoscopy have all improved the quality of the preparation (6–8). In addition, verbal (face-to-face) education was significantly helpful (9). In adult patients, barriers to a good preparation include factors such as obesity, older age, previous colorectal surgery, diabetes, and constipation (10,11). Additional barriers include the patient's lack of ability to manage his own health (known as “patient activation”) (12), and inability to follow preparation instructions (5). At present, neither facilitators nor barriers have been studied in the pediatric population.
The primary aim of this study was to determine if there are barriers and facilitators to a good pediatric bowel preparation for children.
The study followed the qualitative methodology of Interpretive Description, which presumes that theoretical knowledge, clinical knowledge, and a scientific basis inform the study (13). Institutional review board approval was obtained by the Hamilton Integrated Research Ethics Board.
Participants and Setting
Participants were recruited from the McMaster Children's Hospital Pediatric Gastroenterology Clinic (Hamilton, ON) between May 2015 and January 2016. Participants aged 2 to 18 years undergoing elective colonoscopy within the past 6 months, and their parents, were invited to participate in an interview exploring the perceived barriers and facilitators to a successful colonoscopy. Participants undergoing emergency colonoscopy, acutely ill patients, hospitalized patients, and children who were allergic to Pico-Salax were excluded. If English was not the family's spoken language, a translator was provided.
All patients received an evidence-based effective preparation (14,15), which is the current standard regimen at our center: 1 dose of bisacodyl 2 days before the procedure; 2 doses of Pico-Salax (1/4–1 sachet each, based on age) the day before the procedure. Pico-Salax is composed of sodium-picosulfate, magnesium oxide and citric acid. One full sachet is mixed with 150 mL water (with volumes varying based on the dose used). All families received information from the gastroenterologist about the bowel preparation protocol (a written handout and verbal face-to-face information) at the appointment preceding the colonoscopy. Clinic appointments took place 4 to 12 weeks before a nonurgent colonoscopy and within 2 weeks of an urgent colonoscopy. Clinic nurse and after-hours physician contact information was provided for questions arising from the process, allowing for further clarification to be made over the phone.
Data Collection and Analysis
A member of the research team approached eligible participants in the clinic to obtain written consent. Consenting participants completed a one-on-one interview in person. An interview guide was used to direct the discussion (See Supplemental Digital Content, http://links.lww.com/MPG/B292). Each semistructured interview lasted 20 to 30 minutes, and included open-ended questions followed by probing questions. The discussion was aimed at exploring impressions regarding timing, method (verbal, written information) and content of the education material, as well as need for additional resources. In addition, interviews explored tolerability of the bowel cleansing protocol and adverse symptoms. Demographic data and reason for colonoscopy were collected from medical records. The interviews continued until the point of saturation, where no new concepts were elicited from subsequent interviews. For qualitative interviews, evidence suggests that data saturation can occur within 10 interviews, with themes arising as early as 6 interviews (16).
All interviews were recorded digitally and transcribed verbatim. Before transcription, each participant was de-identified and assigned a number to maintain confidentiality and anonymity. Data collection and analysis took place concurrently, allowing researchers to review the interview guide and refine emerging codes and categories. Analysis involved line-by-line coding of transcripts in Microsoft Word, allowing for the identification of recurrent themes and patterns. The codes were categorized into conceptual themes and domains using constant comparison. These themes and domains were then used to refine the preliminary conceptual framework. Coding was performed independently by 2 team members (L.H., H.N.), and confirmed by a third (N.L.). Once the data was fully coded, the barriers and facilitators were identified. Microsoft Excel was used to manage the data.
Eleven families consented to participate and interviews were completed with 21 participants: 7 children and 14 parents. Only one family declined participation, citing a lack of interest in being involved. Fifty percent of the children were under 11 years, and 8 of 11 (73%) were undergoing the bowel preparation for the first time (Table 1). All 11 children had adequate cleanouts that led to complete colonoscopies (with terminal ileum intubation). Participants identified 26 subthemes, which were categorized into 4 broad themes: information needs, process of care, access to care, and preparation experience (Table 2).
Information needs was the most common theme reported. This refers to comments related to the protocol brochure, overall satisfaction with the information, confusion regarding instructions, and advice to others.
The majority of the participants were satisfied with the information they received. Furthermore, most participants felt the layout, language, and content were appropriate and thorough. Despite reporting that the protocol brochure was well done, when questioned further, most participants could find a component of the content that could cause misunderstandings. They therefore provided suggestions on how to improve the preparation sheet. They recommended writing more examples of clear fluids, describing what the end results should be, highlighting/bolding the times that the child can/cannot eat, and clarifying how to mix the solution (especially if the child was taking less than a full sachet). In regards to additional resources, half of them felt a website could be helpful, especially if they misplaced the handout. A quarter felt they could benefit from a video, and that younger children could benefit from a cartoon.
Some of the parents were unclear what to expect by the end of the preparation. They were unsure if the child should still be passing stool the morning of the colonoscopy and what the stool should look like in the hours leading up to the procedure. Without knowing the end goals, these parents were unsure if the child was fully cleaned out.
Children were asked what advice they would provide to others going through the same experience. All advice was encouraging, with participants offering comments such as “don’t worry about it,” “it's not as bad as you think.” More specifically, the children wanted others to know that the taste is the worst part, and that it is important to have easy access to a bathroom.
Process of Care: Bowel Preparation
Process of care was the second most common theme and describes the participant's experience on the day of the bowel preparation. All participants were able to complete the full Pico-Salax doses orally, with only one child needing it syringed into her mouth. Surprisingly, 3 children thought it tasted “okay” and “like orange crush,” while the majority disliked the taste, calling it “sour” or “kind of gross.” Half of the participants did not notice any adverse effects. The remainder commented on side effects including cramping abdominal pain, bloating and gas, perianal discomfort, nausea and vomiting, or overnight wakening. Of the latter group, most experienced at least 2 adverse effects each.
Preparation experience, the third most common theme, refers to the family's perceptions about the bowel preparation and associated challenges. Half felt the bowel preparation went just as expected and half had a better experience than anticipated. While all the children successfully completed the preparation, some parents found it challenging to get the child to drink the medication. Some parents also commented on challenges such as drinking enough clear fluids and not eating solids during the preparation day.
This theme also includes the emotions parents had during the preparation experience. Some of the parents were anxious for the clean out to go well, as they did not want the child to go through the experience again. A few felt an incomplete clean out would reflect poorly on them. Further, if the process was not going as they planned, a few felt confusion about whether or not they had followed the instructions correctly.
Access to Care
Access to care was the fourth most common theme, and encompasses the family's ability to reach out to the GI team and pharmacists. All of the participants found the GI team very helpful and most commented that they were able to reach a team member easily. Of the parents who approached the pharmacist with questions, all found that the pharmacists were generally unfamiliar with bowel preparation for children and were unable to provide guidance.
Bowel Preparation Barriers and Facilitators
Barriers included confusion regarding mixing of the preparation and allowable diet during the preparation day, as well as lack of clarity on expected stool end goals. Some of the parents mentioned that they found pharmacists unfamiliar with the bowel preparation for children. Facilitators included ease of access of the GI team to answer questions, small volume of liquid mixed with the preparation, few adverse effects, and the provision of a handout that was understandable. Parental motivation to achieve a good preparation outcome was also a facilitator (Table 3).
Findings Based on Patient Age
Taking into account the patient's age, the families of the younger children (≤11 years old) had more confusion regarding allowable fluids during the preparation and these parents were more unsure of what to expect as the end point. These families expressed more anxiety and frustration than the older group (≥12 years old). Furthermore, younger children were expected to take 1/4 or 1/2 sachet Pico-Salax; therefore, it was this group that approached the pharmacists for assistance, but encountered difficulty receiving advice due to a lack of familiarity of pharmacists with pediatric bowel preparation. All age groups provided similar comments about the protocol brochure language and content, and the ease of accessibility to the GI team. Interestingly, the younger group did not mind the taste of the medication, but had more adverse effects, such as abdominal pain and vomiting. The older group were surprised that the experience was better than expected, and provided advice such as “don’t worry, it's easy” and “it's not as bad as you think.”
In this qualitative study, we examined the bowel preparation experience for pediatric patients undergoing colonoscopy. One-on-one interviews with parents and children allowed for a better understanding of the family's experience from beginning to end. The most surprising finding was the role of parental motivation and anxiety in the bowel preparation process. Parents felt a sense of pressure to achieve an effective cleanout and this acted as a facilitator to a successful preparation. Other unique findings include pharmacists’ lack of familiarity with pediatric preparation medication, and for the younger patients, uncertainty of what to expect as the end point of the preparation. They also had relatively little objection to the taste of the medication. For the older patients, the preparation experience was reported as better than anticipated.
Emerging themes focused on participants’ informational needs. Research indicates that ensuring the families fully understand the bowel preparation process is one of the most important components to ensuring an effective cleanout (17). In keeping with this, providing verbal and written information acted as a facilitator to a good preparation. Furthermore, education literature indicates that utilizing both the visual-pictorial channel of information processing (written) and the auditory-verbal pathway (verbal) lead to better gains in knowledge than either one alone (18). Given that both pathways were utilized through written handout and verbal information, it is not surprising that the participants were satisfied with the information received. Participants, however, provided topics that either needed further clarification or should be included in the protocol document. It was important to elicit this feedback, as collaborating with families is an important component of the patient-centered approach. Furthermore, family participation in quality improvement initiatives lead to more effective use of health care resources (19). We should therefore continue to encourage and facilitate opportunities for families to be involved in patient care, education initiatives, and program development.
Although access to the GI team was a facilitator, local pharmacists inexperience with pediatric patients was a barrier to a good preparation. The former is consistent with adult data that telephone re-education of patients improves outcome (6). Regarding the latter, pharmacists recognize that providing medication information is a professional responsibility, and for common conditions, they have appropriate expertise (20). When Munzenberger et al, however, surveyed 95 pharmacists about their pediatric training, they did not feel knowledgeable enough to educate about less common conditions. Hence, while the prevalence of pediatric colonic diseases have been increasing, they remain “less common” conditions, and understandably, pharmacists may feel uncomfortable advising about colonoscopy preparation. Therefore, we would recommend providing very clear mixing instructions to parents or providing pharmacists with further education on pediatric bowel preparations.
Specific to the day of the preparation, all patients reported disliking the taste of the medicine; however, they were all able to finish both doses of Pico-Salax. Hunter and Mamula (21) reviewed data on bowel preparation medications for children. Beyond efficacy, they concluded that bad taste, large volume and diet restrictions during clean out all decrease compliance. Hence, the ideal preparation would be palatable, low volume and effective. Vejzovic et al, who conducted a qualitative assessment of children's experience with in-hospital bowel preparations, found similar results. The children had difficulties ingesting a large volume of preparation (PEG3350) and described the taste as “disgusting, bad, awful” (22). Since Pico-Salax led to completed colonoscopies in all of our participants, using a low volume medication may be a facilitator to a successful preparation, and we would recommend it be more widely used.
Another facilitator to a good bowel preparation was the presence of few adverse effects from the medication. Only half of the participants experienced side effects, and they were still able to complete the preparation. One other prospective study (23) cited similar findings, whereby, using PEG3350 bowel preparation, only 30% had mild adverse effects. Similar to our study, the main side effects also noted by Hunter and Mamula, were abdominal pain, bloating, vomiting, and sleep disturbance (21). Interestingly, despite the side effects, the patients rated the experience to be “as expected” or “better than expected.” Hence, they recognized the necessity of the bowel preparation, but realized that it may not be pleasant. In fact, when explaining what made the experience “as expected” or “better than expected,” participants commented on the bad taste of the medication and the frequency of the bowel movements, rather than the side effects. Therefore, if side effects do not prevent patients from having a successful cleanout, it may be worthwhile to continue to focus efforts on how to make the preparations more palatable.
A few parents found the experience to be very anxiety provoking, as they were unsure what to expect by the end of the preparation, leading them to question if they had followed the instructions correctly. Most interestingly, they felt a sense of pressure to complete the cleanout successfully. Without endorsing parental anxiety, parental motivation to achieve a complete cleanout acted as a facilitator to a successful bowel preparation. This goes in accordance with the study of Vejzovic et al on parental perceptions during an in-hospital bowel preparation. Similar to our study, the parents feared the colonoscopy would not be completed if the bowel was not clean enough, and the family would risk having to go through the process again. Although Vejzovic et al (24) found that parents perceived themselves as mean, feeling “forced to force” the child to drink, the parents in our study, however, did not describe their experience in such extreme terms. They were creative in their methods of providing the child with liquids and they were impressed by the child's ability to comply with the instructions. Parental motivation and involvement in the process can therefore be extremely helpful in ensuring success, and is highly recommended in these situations. Furthermore, providing families with a list of creative methods to help the children drink the liquids may be another way to help improve outcomes.
The qualitative approach enabled us to examine the real experiences of children undergoing colonoscopy. We, however, recognize there are limitations to our study. This was a single-center study, using only one bowel preparation protocol. Therefore, it is difficult to determine if the same barriers and facilitators would hold true had other protocols been used. Only the volume, taste, and mixing instructions (on the box) directly pertain to the type of medications used; therefore, we can, however, expect the remainder of the results to be generalizable. In addition, there may have been selection bias as we were unable to interview patients who could not complete the preparation process. We therefore hope that our findings will inspire larger studies to explore similar bowel preparation-related themes in the pediatric population and correlate them with objective bowel cleanliness during colonoscopy.
This is the first qualitative study identifying the challenges children face when undergoing bowel preparation in the home setting. The participants focused most on their informational needs, particularly around bowel preparation instructions, description of diet requirements, and understanding of the appropriate end point of the cleanout. We recommend providing families with such details, in both verbal and written instructions, to ensure optimal outcomes. Parental involvement in the process was an asset, as was low volume preparation and few adverse effects. While the type of preparation may be dependent on availability by country, keeping parents involved and motivated is essential to ensure success. Furthermore, we should continue to provide opportunities for families to be involved in patient care and education initiatives. With the identification of barriers and facilitators, more focused quality improvement measures for pediatric colonoscopy preparation may be undertaken.
The authors thank Dr Anne Klassen, Associate Professor, McMaster University, and Dr Sharon Marcovitz, transcription services, for their support.
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