Rev. paul. pediatr. vol.34 número4

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REVISTA

PAULISTA

DE

PEDIATRIA

www.rpped.com.br

ORIGINAL

ARTICLE

Pediatrician’s

knowledge

on

the

approach

of

functional

constipation

Mario

C. Vieira

a,b

,

Isadora

Carolina

Krueger

Negrelle

a

,

Karla

Ulaf

Webber

a

,

Marjorie

Gosdal

a,∗

,

Sabine

Krüger

Truppel

b

,

Solena

Ziemer

Kusma

a

a_Pontifícia_Universidade_Católica_do_Paraná,_Curitiba,_PR,_Brazil

b_Hospital_Pequeno_Príncipe,_Curitiba,_PR,_Brazil

Received12February2016;accepted29May2016 Availableonline6September2016

KEYWORDS

Constipation; Pediatrics; Diagnostic; Treatment

Abstract

Objective: Toevaluatethepediatrician’sknowledgeregardingthediagnosticandtherapeutic approachofchildhoodfunctionalconstipation.

Methods: A descriptive cross-sectionalstudy was performedwith theapplication ofa

self-administered questionnaire concerning a hypothetical clinical case ofchildhood functional

constipationwithfecalincontinencetophysicians(n=297)randomlyinterviewedatthe36th BrazilianCongressofPediatricsin2013.

Results: The majorityoftheparticipants werefemales, the meanage was44.1years,the meantimeofprofessionalpracticewas18.8years;56.9%wereBoardCertifiedbytheBrazilian SocietyofPediatrics.Additionaltestswereorderedby40.4%;includingabdominal

radiogra-phy (19.5%), barium enema (10.4%), laboratory tests (9.8%), abdominal ultrasound (6.7%),

colonoscopy(2.4%),manometryandrectalbiopsy(both1.7%).Themostcommoninterventions

includedlactulose(26.6%),mineraloil(17.5%),polyethyleneglycol(14.5%),fibersupplement (9.1%)andmilkofmagnesia(5.4%).Nutritional guidance(84.8%),fecal disimpaction(17.2%) andtoilettraining(19.5%)werealsoindicated.

Conclusions: Ourresultsshowthatpediatriciansdonotadheretocurrentrecommendationsfor

themanagementofchildhoodfunctionalconstipation,asunnecessarytestswereorderedand

thefirst-linetreatmentwasnotprescribed.

∗_{Corresponding}_author.

E-mail:marjorie.gosdal@hotmail.com(M.Gosdal).

http://dx.doi.org/10.1016/j.rppede.2016.06.003

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PALAVRAS-CHAVE

Constipac¸ão intestinal; Pediatria; Diagnóstico; Tratamento

Conhecimentodopediatrasobreomanejodaconstipac¸ãointestinalfuncional

Resumo

Objetivo: Identificaroconhecimentodopediatraquantoaomanejodiagnósticoeterapêutico dacrianc¸acomconstipac¸ãointestinalfuncional.

Métodos: Estudo transversal descritivo comamostra constituída de médicos (n=297)

entre-vistados no 36◦ _Congresso _Brasileiro _de _Pediatria _de _2013. _Foi _usado _um _{questionário}

autoadministradoreferenteaumcasoclínicohipotéticodeconstipac¸ãointestinal.

Resultados: Foiobservadamaiorproporc¸ãodepediatrasdosexofeminino,médiade44,1anos,

tempo de formac¸ão médio de 18,8 anos, 56,9% portadores de título de especialista pela

SociedadeBrasileiradePediatria.Examescomplementaresforamsolicitadospor40,4%,a

radio-grafia abdominalfoi omais requisitado(19,5%), seguidopor enemaopaco (10,4%),exames

laboratoriais(9,8%),ultrassonografia de abdome(6,7%),colonoscopia (2,4%),manometriae

biópsia(ambas1,7%).Paraomanejofoisugeridaaprescriçãodelactulose(26,6%),óleo min-eral(17,5%),polietilenoglicol(14,5%),suplementodefibras(9,1%)eleitedemagnésia(5,4%). Orientaçãoalimentar(84,8%),desimpactaçãofecal(17,2%)etreinamentodetoalete(19,5%)

tambémforamindicadas.

Conclusões: Evidencia-seumadiscordânciaentreomanejosugeridopelospediatrasea con-dutapreconizadapelaliteraturadisponívelatualmente,umavezqueforamsolicitadosexames

complementaresdesnecessáriosenãofoirecomendadaaorientac¸ãoterapêuticaconsiderada

deprimeiralinha.

Introduction

In clinical practice,intestinal constipation is a very com-monfindinginchildren,correspondingtoapproximately3% ofconsultationsingeneralpediatricoutpatientclinicsand 25%ofconsultationsinpediatricgastroenterology.1---4_When

assessingthestudiesinBrazil,avariationof14.7---38.8%was

foundintheprevalenceofconstipation.5_This_wide_variation

isdueboth totheheterogeneityof thediagnosticcriteria

andthedifferencesinstudypopulationselection.5,6

TheRomeIIICriteria(2006)statesthatinchildrenolder

than 4 years, the diagnosis of constipation is established

when thereare ≤2 bowel movements per week; at least

oneepisodeoffecalincontinenceperweek;historyof

reten-tivepostureorexcessivevoluntarystoolretention;historyof

painfulbowelmovements;presenceofalargefecalmassin

therectalcanal;historyoflarge-caliberstoolsthatcanclog

thetoiletbowl.Thesymptomsmustbepresentatleastonce

aweekfora two-monthinterval.4_However,_these_criteria

areconsidered by some experts as very restrictive.5 _The

European Society of Pediatric Gastroenterology,

Hepatol-ogyand Nutrition (ESPGHAN) and North-American Society

of Pediatric Gastroenterology, Hepatology and Nutrition

(NASPGHAN)guidelinesrecommendusingtheRomeIII

crite-ria,exceptforsymptomduration,sincetherecommended

intervaloftwomonthscancontributetotreatmentdelayin

olderchildren.7

Thehighprevalenceofconstipationgenerateshighcosts

topublichealth,representinganexpenseofUS$3362per

childtreated annuallyin theUnitedStates.6 _Studies _have

shownthat thereis nopredominance of gender andin at

leasthalfofthecasesconstipationoccursinthefirstyear

of life, even if it is more often diagnosed in school age

children.1,3

Complications associated with constipation include

recurrentabdominalpain,fecalincontinence,rectal

bleed-ing, enuresis and urinary infection/retention.6 _These

aggravatingfactors mayprogressivelyassociate and

nega-tivelyinfluencethequalityoflife,generatingcostsforboth

thefamilyandthegovernment.2,3

Althoughitisadiseasewitharelativelysimplediagnosis

andtreatment,constipationaffectsthechild’sphysicaland

emotional integrity.1 _Taking _into_account _the _prevalence,

clinical significance and impactof the disease, this study

aimstooutlineamanagementpanoramaadoptedby

Brazil-ianpediatricianswhen treatingacaseof constipationand

establishaparallelwiththeavailableliterature.

Method

Thiswasacross-sectional,descriptivestudy,withasample of297physicianschosenbynonrandomconvenience samp-ling,participatingin36thBrazilianCongressofPediatrics,in Curitiba,stateofParaná,inOctober2013.Thecongress par-ticipantswereapproachedbyindividualresearchersduring theintervalsofscientificactivitiesandinvitedtoparticipate andanswerthequestionnaire.

The study was approved by the Institutional Review Board of Pontifícia Universidade Católica do Paraná and written consent was obtained from all respondents. The study included pediatricians, general practitioners with a Specialist title in Pediatrics by the Brazilian Society of Pediatrics(SBP)andmedicalresidentsinPediatrics.A self-administeredquestionnaireconsistingoftwopartswasused astheresearchtool.

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drawingtherespondent’s medicalprofile,by gender, age, origin,timesincegraduation,extendededucationandplace ofwork.

The second part of the questionnaire reported to the followingfictitiousclinicalcase: ‘‘J.L.C.,malegender, six yearsold,hasonebowelmovementeverythreeorfourdays, drystools,painandeffortatevacuation.Hesoilshisclothes threetofourtimesaweek.Onphysicalexamination:height 118cm and weight, 21.4kg. He shows palpable hardened fecesintheleftiliacfossainmoderatequantity.Nomore details’’.Thisstepcontaineddiscursiveopenquestions con-cerningthediagnosisandinitialclinicalmanagement,which were:I.Whatisthemostprobablediagnosisfor thiscase? II. Whatarethecriteriausedfor thisdiagnosis?III. Would youindicateanyfurtherexaminations?Ifso,whichones?IV. Whatwouldbethetherapeuticmanagementofthispatient? Ifyouchoose medication,whichwouldbethedrugandat whatdose? Atotalof412questionnairesweredistributed, of which346 were answered.Of these,49 questionnaires wereexcluded,astheywereincompleteorillegible.

The Rome III criteria (2006) were considered for the diagnosisoffunctionalconstipation.Theanswersobtained fromthe questionnaireswere transcribed and stored in a Microsoft Excel® ₂₀₁₀ _spreadsheet. _Mean, _median,

mini-mum,maximumandstandarddeviationvalueswereusedto describequantitativevariables.Qualitativevariableswere described asfrequenciesandpercentages. The chi-square test or Fisher’sexact test wasusedtoevaluate the asso-ciationbetweentheparticipants’profilevariablesandthe prescription/indication variables.Pvalues<0.05were con-sidered statistically significant. Datawere analyzed using theIBMSPSSsoftwarev.20.0.

Results

A total of 297 questionnaires were included. Among the interviewedpopulation,therewasaslightpredominanceof females(58.9%).Themeanagewas44.1years(23---75)and the meannumber of the yearssince graduationwas 18.8 (0---52).Themajorityofrespondentscamefromthe South-eastregion(45.5%),followedbytheSouth(26.3%),Central West (8.4%), Northeast (12.1%) and North (7.7%) regions. Mostof theintervieweddoctors(60.9%) hada Board Cer-tificationtitleby theBrazilianSociety ofPediatrics(SBP), whiletherestconsistedofpediatricianswithoutboard certi-ficationandpediatricresidents.Ofthetotal,89doctorshad adegreeinthepediatricarea,ofwhichseven(2.4%)were pediatric gastroenterologists. General information about thestudypopulationisdetailedinTable1.

Thediagnosisofconstipationwasidentifiedby93.6%of

respondents.Complementarytestswereindicatedby40.4%,

with plain abdominal radiography being the most often

requested test(19.5%). Bariumenema (10.4%),abdominal

ultrasonography(6.7%), anorectal manometry (1.7%),

rec-tal biopsy (1.7%),colonoscopy (2.4%)and laboratory tests

(9.8%)werealsomentioned(Table2).

As for the management proposed by the respondents,

itis noteworthythat84.8% wouldmakerecommendations

relatedtothepatient’seatinghabits.Regardingother

non-pharmacological measures, they also mentioned the use

of additional fiber (9.1%) and toilet training (19.5%). A

Table1 Characteristicsofrespondents(n=297).

Variables Description n(%)

Gender Female 175(58.9)

Male 122(41.1)

Timesince graduation

Mean 18.8years

Region North 23(7.7)

Northeast 36(12.1)

Midwest 25(8.4)

Southeast 135(45.5)

South 78(26.3)

Educational back-ground

Residencyin PediatricswithBCPa

170(57.2)

Residencyin Pediatricswithout BCPa

64(21.6)

ResidentPhysician (1styear)

27(9.1)

ResidentPhysician (2ndyear)

25(8.4)

GeneralPractitioner andBCPa

11(3.7)

Pediatric spe-cialty

Gastroenterology 7(2.4) Others 82(27.6)

No 208(70.0)

a _BCP,_Board_{Certification}_in_Pediatrics_granted_by_the_Brazilian

SocietyofPediatrics/BrazilianMedicalAssociation.

pharmacological approach was recommended by 64% of respondents and included the use of lactulose (26.6%), mineraloil(17.5%),polyethyleneglycol(PEG)(14.5%)and magnesiumhydroxide(5.4%).Noneoftheresponses recom-mendedtheuseofmorethanonelaxativesimultaneously. Fecal disimpaction was suggested by 17.2% of the inter-viewedphysicians(Table3).

An association was identified between the time since

graduationandcertainconductsinthediagnosticand

ther-apeuticmanagement(Fig.1).Amongthedoctorsthathad

graduatedlessthansixyearsbefore,4.6%wouldrequestan

abdominalultrasound.Incontrast,14.4%ofthosethathad

Table2 Diagnosticmethodsproposedbyrespondents.

Category n(%)

Needforcomplementaryexaminations

Yes 120(40.4)

No 177(59.6)

Requestedexaminations

Abdominalradiography 58(19.5)

Abdominalultrasonography 20(6.7)

Bariumenema 31(10.4)

Manometry 5(1.7)

Biopsy 5(1.7)

Colonoscopy 7(2.4)

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Table 3 Therapeutic management proposed by respondents.

Suggestedtreatment n(%)

Fecaldisimpaction 51(17.2)

Polyethyleneglycol 43(14.5)

Lactulose 79(26.6)

Mineraloil 52(17.5)

Magnesiumhydroxide 16(5.4)

Fibersupplement 27(9.1)

Nutritionalguidance 252(84.8)

Toilettraining 58(19.5)

graduated morethan 30 years beforewould dothe same (p=0.034).

Regarding the use of polyethylene glycol, it was indi-catedby21.5%ofdoctorsthathadgraduatedlessthansix yearsbeforeand20.6%ofthosegraduatedbetween6and 15 years before,with a lower percentage of prescription among the ones that had graduated more than 15 years before(p=0.046).

Approximately 30% of each group of respondents with timesincegraduationless than30yearsprescribed lactu-lose. Respondents that had graduated between 6 and 15 yearsprescribedmagnesiumhydroxideatahigher percent-age (14.3%) when compared to the other groups of time sincegraduation.This drugwasprescribedby1.4%of pro-fessionalsthat hadgraduated morethan 30 yearsbefore, by 1.5% among those with less than 5 years since grad-uation and 3.1% among those that had graduated 16---30 yearsbefore(p<0.001).Amongthosethathadgraduatedless than6yearsbefore,33.9%indicatedfecaldisimpaction,as 25.4%ofthosegraduated6---15yearsbefore;9.3%ofthose

graduated 16---30years beforeand5.8% ofthosethat had graduatedmorethan30yearsbefore(p<0.001).

Discussion

There can be several etiologies for constipation. Func-tional constipation is the most common, in which the most important originating factor seems to be voluntary fecal retention.2,4 _Organic _causes _of _constipation _include

metabolicdisorders(hypothyroidism,cysticfibrosis,

hyper-calcemia and hypocalcemia), neuropathic (Hirschsprung’s

disease, myelomeningocele, spina bifida, cerebral palsy)

andimmunologicaldiseases(allergytocow’s milkprotein,

celiacdisease),aswell asthe useof medicationssuchas

ironsalts,antacids,anti-inflammatorydrugsandopioids.3,5

TheRomeIIICriteria(2006)istheonemostoftenusedto

determine constipationinchildhood.1,7---9 _In_the

aforemen-tionedclinicalcase,symptomdurationwasnotstated(if>2

months), a factor that can be considered a study

limita-tion.The ESPGHAN andNASPGHAN guidelinesrecommend

thattheRomeIIIcriteriabeusedtodefinethepresenceof

constipation,exceptforsymptomduration,consideringthat

thetwo-monthintervalrecommendedforolderchildrencan

contributetotreatmentdelay.7

The practical guide proposed by National Institute for

HealthandClinicalExcellence(NICE)statesthatadetailed

historyandathoroughphysicalabdominalexaminationare

enoughtoattainthediagnosis.10_This_is_also_the_final

conclu-sionoftheguidelinesproposedbyESPGHANandNASPGHAN,

suggesting thatthe diagnosisis primarily clinical andthat

complementary tests are not necessary to confirm the

disease.7 _{Nevertheless,} _40.4% _of _the _respondents _deemed

necessarytorequestadditionaltests.

40.00%

35.00%

30.00%

25.00%

20.00%

15.00%

10.00%

5.00%

0.00%

Abdominal US PEG Milk

of magnesia

Lactulose Fecal

disimpaction (p=.034)

4.62% 3.17% 5.15% 14.49%

21.54% 20.63% 8.25% 11.59%

30.77% 34.92% 28.87% 13.04%

1.54% 14.29% 3.09% 1.45%

33.85% 25.40% 9.28% 5.80% (p=.046) (p=.023) (p<.001) (p<.001)

Up to 5 years 6 to 15 years

16 to 30 years

>30 years

(5)

A plain abdominal radiography may be useful to char-acterize fecal impaction in children and to evaluate the effectiveness of the initial treatment.11 _However,_despite

beingrequestedby58 physicians(19.5%),itis not

consid-ered necessary to attain a final diagnosis, as thereis no

association betweenthepresence ofsuggestive symptoms

and the accumulation of stool in the rectum.8 _It _is

note-worthythat therearenostudies associating theneed for

abdominalradiographywhenthepatientdoesnotmeetthe

clinicalcriteriaforconstipation.7,11,12

Abdominalultrasoundwasanotherveryoften-indicated

test. Twenty professionals (6.7%) found it necessary to

requestthisexaminationtoconfirmthediagnosis.Inspiteof

beingseen asasimple,noninvasivemethodfor evaluation

offecalretentionandmeasurementofthetransverserectal

diameter,itisnotconsideredanessentialexamination.1,7,13

Todate,thereisnotenough evidenceestablishingthatan

alterationinrectaldiametercanbeusedasapredictorfor

thepresenceofconstipationinchildren.11,14

The barium enema was indicated by 10.4% of

respon-dents.Accordingtotheliterature,thisis oneofthemain

testsusedtoruleoutthemostimportantdifferential

diag-nosisforfunctionalconstipationinchildren,Hirschsprung’s

disease.15,16_However,_this_test_is_not_required_for_the_final

diagnosis,unlessthechildhassuggestivesigns,suchasan

earlyonsetof constipation,delayedpassageof meconium

andsignificantabdominaldistension.7,15

The sameis truefor anorectalmanometry (ARM),

indi-catedbyfiveoftheinterviewedphysicians(1.7%).Thistest

also aimsto rule out Hirschsprung’s disease by disclosing

alterationsintheanorectalinhibitoryreflex.17---20_However,

itisnoteworthythattheexaminationisnotessentialforthe

diagnosis,especiallyinchildrenaftertheneonatalperiod.7

Aswiththebariumenema, ARMshouldonlybeperformed

ifthereare datasuggestive ofHirschsprung’s disease and

inseverecasesrefractorytoadequatetreatment.7,17,20_The

rectalbiopsyisconsideredthegoldstandardforthe

diagno-sisofHirschsprung’sdiseaseandshouldonlybeperformed

when the tests discussed above suggest itspresence.12 _It

should not be performed at the patient’s initial

consul-tation, unlike what was proposed by seven professionals

interviewedinthisstudy(2.4%).7

Colonoscopy wasanotherexaminationsuggestedbythe

interviewedphysicians(1.7%).Aswiththeanalysisofcolonic

transit,thecolonoscopyshouldnotbeindicatedattheinitial consultations.7

Finally,laboratory testswererequestedby29

pediatri-cians (9.8%). Such tests may be indicated when there is

diagnosticuncertainty (patientdoes notmeet theclinical

criteria),orwhenthereisstrongsuspicionofanunderlying

organic disease, such ashypothyroidism, allergy tocow’s

milk proteinand celiacdisease and not for patients with

aclear pictureof functionalconstipation, asinthisstudy

case.1,7,10,15

Thehypothesisoffunctionalconstipation2_should_prevail

inthemanagementofthechildwithconstipation,ifthere

are no data in clinical history and physical examination

suggesting asecondary cause.Traditionally,the

therapeu-tic management consists of four steps, including general

recommendations and education, disimpactionwhen

nec-essary, re-impaction prevention and retraining of bowel

habits.4_When_transmitting_the_general_{recommendations,}_it

isimportanttoestablishacooperativerelationshipbetween

thephysicianandthefamily,includingthepatients,when

their age allows it.2,7,21 _The _basic _{understanding} _of _the

pathophysiologyinvolvedhelpstoeasefamilytensionsand

feelingsofinsecurityorguilt.2,21

A balanced diet, including the consumption of whole

grains, fruits and vegetables, together with an adequate

waterintake,isrecommendedaspartofthemaintenance

treatmentforconstipationinchildren.4_Among_the

respon-dents,84.8%suggested sometypeof nutritionalguidance.

There are conflicting reports in the literature about the

roleoffiberintakeinchildrenwithconstipation.However,

supplementationwithsolublefiber, considered by9.1% of

thepediatricians,hasnotshownsufficientefficacyandits

useisnotindicated.4,7

The toilettraining goalshouldbe toretrain thebowel

habits.2,4 _The_child _should_be_advised _to_remain_sitting_on

the toilet bowl for 5---10min after the main meals, in an

adequate position for the abdominal press, while using a

footrest.1,4_Among_the_interviewed_physicians,_19.5%_made

recommendationsaboutpatienttoilettraining.

The elimination of the fecaloma through fecal

disim-pactionshouldbeperformedwhenthepresenceofamass

isidentifiedduringabdominalpalpation,rectalexamination

orplain abdominalradiography.4 _The _disimpaction_can_be

madewithenemasorlaxatives,suchaspolyethyleneglycol

(PEG), with both being of similar efficacy.22 _As _the

pro-posedclinicalcase showedevidenceof fecalretention on

thephysicalexamination,fecaldisimpactionwouldbe

indi-cated.However,theprocedurewasconsideredbyonly17.2%

ofthepediatricians.Noneoftherespondentsspecifiedthe

typeoffecal disimpaction(orally or byenema). Itshould

be noted that the disimpaction before the maintenance

therapyisrecommendedtoincreasetreatmentsuccessand

reducetheriskoffecalincontinence.1,4,18 _Once_the

disim-paction is performed, the focus of the treatment should

be recurrence prevention with the use of maintenance

medications.1,21

The pharmacological approach was recommended by

64% of respondents. Among the drugs used totreat

con-stipation,polyethylene glycol (PEG) is the most effective

when comparedto lactulose, magnesium hydroxide,

min-eraloilor placebo.7_PEG_is _a_compound_of_high_molecular

weight,poorlyabsorbedbythebodyandnotmetabolizedby

intestinalbacteria.17,23 _It _exerts_an _osmotic,_{non-irritating}

action, withconsequentincrease in the water contentof

stools.17,23 _It_should_be_considered_as_the_first-line

mainte-nancetreatment ofintestinalconstipation.7,23 _However,_it

wasprescribed by only 14.5% of the respondents. A

con-siderablyhighernumberofpediatricians(26.6%)indicated

theuseoflactulose.Several studiescomparingtheuseof

PEGandlactulose suggestedthe superiorityof PEG

treat-ment,highersuccessratesinthetreatmentandprevention

offecalimpactionrecurrence,greaterreliefof abdominal

painandfewersideeffects.24---27_The_maintenance_treatment

withlactuloseisrecommendedwhenPEGisnotavailable.7

Therefore,aninversionintheprescriptionratesofPEGand

lactulosecan beobserved inthe availableliterature. The

prescriptionofmagnesiumhydroxide,consideredby5.4%of

pediatriciansandofmineraloil,prescribedby17.5%,should

beusedasadjunctivetherapyorsecond-linetreatmentof

(6)

Early adequate treatment of constipation is

essen-tialto preventcomplications, suchasfecal incontinence,

describedinourcase. Whenanalyzing theconductstaken

bytherespondents,oneshouldconsiderthelocationwhere

each professionalworks,taking into accountpossible

dif-ferences in the availability of resources, both diagnostic

andtherapeutic.Some statisticallysignificantassociations

(p<0.05) were observed between the respondent’s profile

andsome of the approaches used.The professionals that

hadgraduatedmorethan30yearsbeforeweremorelikely

to request an abdominal ultrasound; 14.5% of this group

requested this test, considered unnecessary for the

dis-ease diagnosis. In contrast,this same group wasthe one

that showed the least number of lactulose prescriptions

in patient management: only 13.4% chose this drug,

ver-sus 34.9% of professionals that had graduated6---15 years

before(Fig.1).Polyethyleneglycolandfecaldisimpaction,

consideredthefirstchoiceforthepatientpresentedinthe

study, were more often indicated by physicians that had

lesstimesincegraduation.1,2_In_relation_to_PEG,_it_was

pre-scribedby21.5%ofphysiciansthathadgraduatedlessthan

sixyearsbeforeand20.6%ofphysiciansthathadgraduated

6---15 yearsbefore.As for fecaldisimpaction, it was

indi-catedby33.8%oftheonesthathadgraduatedlessthansix

yearsbeforeand25.4%ofthosegraduated6---15yearsbefore

(Fig.1).Doctorsthathadgraduatedbetween6and15years

beforewere the ones that most often prescribed

magne-siumhydroxide(14.3%),which isconsidered asecond-line

or adjunctivetherapy drug(Fig.1).These results

demon-stratethegreatdisparityinthetypeofmanagementusedby

physicianswithlongertimesincegraduationandthosewith

lesstime,whichreinforcestheneedforconstantupdating

byhealthprofessionals.

Recent studies, published after data collection was

finished for this study, showed differences in behaviors

proposedbygeneralpractitioners, pediatriciansand

pedi-atric gastroenterologists.28,29 _A _study _carried _out _in _Saudi

Arabia, which used a questionnaire with questions about

practicalanddemographiccharacteristics,definition,

man-agement and treatment of constipation, showed that

pediatricians more often prescribed the use of lactulose

and indicated fecal disimpaction when compared to

gen-eral practitioners.28 _A _national _study _performed _in ₂₀₀₉

withphysicians inthe state of Minas Gerais, showedthat

72.6%ofpediatricgastroenterologistsrequestedadditional

tests,whencomparedwith27.5%oftheotherinterviewed

physicians.29 _The _study _also_disclosed_that_the _most_often

recommendeddrugs bynon-gastroenterologists were

min-eral oil (72.6%), magnesium hydroxide (52.1%), lactulose

(41%)andPEG(25.2%).Amongthepediatric

gastroenterolo-gists,themostoftenrecommendeddrugsweremagnesium

hydroxide (91.7%), PEG (91.7%) and mineral oil (58.3%).

These studies included the administration of a

question-naireonconstipation,incomparisonwiththepresentstudy,

which used an open clinical case as part of the research

tool.

Thelimitationsofthepresentstudyincludethefactthat

itisacross-sectionalone,thatitidentifiedthephysician’s

circumstantialidea inrelation toa specific case, andthe

inclusionof physicians whowere pediatric residents. One

shouldalso considerthat the selection of respondents by

conveniencehastheadvantageofevaluatinganaccessible

population,butresultsintheincapacitytomakestatements

that can be strictly generalizable. The results obtained

mightdepictagoodimageoftheconductsuggestedbythe

pediatricians;however, itis notpossible touse statistical

toolstomeasuretheaccuracyofresults.

Despitetheabovementionedlimitations,theinadequacy

in diagnosticand therapeuticproceduresdemonstrated in

this study highlights the need for continuing education

programs in order to update pediatricians regarding the

managementofintestinalconstipation.Themistakesmade

indiagnosticmanagementsubjectthepatientto

unneces-sary tests, which are often invasive and do not influence

the recommendedapproach. The useof therapies

consid-eredassecond-lineonesasthefirsttreatmentoptionmay

resultintreatmentfailureorrefractorydisease.Treatment

delaysandinadequatetreatmentsmayresultintheonset

ofcomplications,negatively influencingthechild’squality

oflifeandgeneratecostsforboththefamilyandthehealth

system.

Funding

Thisstudydidnotreceivefunding.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

References

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